Change Request
 

NHS Connecting for Health

NHS Data Model and Dictionary Service

Reference: Change Request 1140
Version No:1.0
Subject:March 2010 Update Patch
Effective Date:Immediate
Reason for Change:Patch
Publication Date:29 March 2010

Background:

This patch updates the NHS Data Model and Dictionary in preparation for the March 2010 Release.

This patch includes:

Summary of changes:

Diagrams
APPOINTMENTS   Changed Diagram
LISTS   Changed Diagram
PATIENT PATHWAY   Changed Diagram
PERSON AND PERSON PROPERTY   Changed Diagram
PRESCRIBING AND DISPENSING   Changed Diagram
 
Data Set
ACUTE MYOCARDIAL INFARCTION DATA SET   Changed Aliases, Description
CANCER REGISTRATION DATA SET   Changed Aliases, Description
DIABETES DATA SET (SUMMARY CORE)   Changed Aliases, Description
GENITOURINARY MEDICINE CLINIC ACTIVITY DATA SET   Changed Aliases, Description
MENTAL HEALTH MINIMUM DATA SET   Changed Aliases, Description
NATIONAL CANCER DATA SET   Changed Aliases, Description
NATIONAL CANCER WAITING TIMES MONITORING DATA SET   Changed Aliases, Description
NATIONAL JOINT REGISTRY DATA SET   Changed Aliases, Description
RADIOTHERAPY DATA SET   Changed Aliases, Description
SEXUAL AND REPRODUCTIVE HEALTH ACTIVITY DATA SET   Changed Aliases, Description
 
Supporting Information
ADMINISTRATIVE CODES AND CLASSIFICATIONS   Changed Description
ADMITTED PATIENT FLOWS DATA SET OVERVIEW   Changed Description
ADMITTED PATIENT STOCKS DATA SET OVERVIEW   Changed Description
BOOKINGS ADMITTED PATIENT AND OUT-PATIENT PROVIDER DATA SET OVERVIEW   Changed Description
CASEMIX SERVICE   Changed Description
CDS ADDRESSING GRID   Changed Description
CLINICAL DATA SETS MENU   Changed Description
DEFAULT CODES SUMMARY TABLE   Changed Description
LEARNING DIFFICULTY   Changed Description
LEARNING DISABILITY   Changed Description
NON-CONTRACT ACTIVITY   Changed Description
ORGANISATIONS INTRODUCTION   Changed Description
PUBLICATION INFORMATION CONTACT DETAILS   Changed Description
SECONDARY USES SERVICE   Changed Description
SUMMARISED ACTIVITY FLOWS DATA SET OVERVIEW   Changed Description
SUMMARISED STOCKS DATA SET OVERVIEW   Changed Description
WHAT'S NEW: MARCH 2010 renamed from WHAT'S NEW: JANUARY 2010   Changed Name, Description
 
Class Definitions
GENERAL MEDICAL PRACTITIONER   Changed Aliases
PATIENT   Changed Attributes
PATIENT ORGANISATION   Changed Attributes
PRESCRIPTION   Changed Description
 
Attribute Definitions
ADMINISTRATIVE CATEGORY CODE   Changed Description
CANCER REFERRAL TO TREATMENT PERIOD START DATE   Changed Description
DEATH LOCATION TYPE   Changed Description
INTERPRETER REQUIRED INDICATOR   Changed Description
PERSON IDENTIFIER   Changed Description
POSSUM SCORE (AFTER SURGERY)   Changed Aliases, Description
POSSUM SCORE (AT DIAGNOSIS)   Changed Aliases, Description
REQUEST CATEGORY   Changed Description
SOCIAL SERVICES CLIENT IDENTIFIER renamed from SOCIAL SERVICE CLIENT IDENTIFIER   Changed Name
SPECIAL EDUCATIONAL NEED TYPE   Changed Description
 
Data Elements
ADMINISTRATIVE CATEGORY   Changed Description
ADMITTED PATIENT ELECTIVE ADMISSIONS   Changed Description
CDS SENDER IDENTITY   Changed Description
CLINICAL CONTACT DURATION OF APPOINTMENT   Changed Description
CONSULTANT CODE   Changed Description
DEFERRED ADMISSIONS (ORDINARY)   Changed Description
HOSPITAL PROVIDER SPELL NUMBER   Changed Description
ORGANISATION CODE (CODE OF PROVIDER)   Changed Description
ORGANISATION CODE (PCT OF RESIDENCE (MOTHER))   Changed Description
PATIENTS FAILED TO ATTEND   Changed Description
PATIENTS REGISTERED BUT NOT OFFERED AN APPOINTMENT TOTAL   Changed Description
PATIENTS REPORTING SYMPTOMS TOTAL   Changed Description
PATIENTS WAITING FOR ADMISSION   Changed Description
PATIENTS WAITING FOR DIAGNOSTIC TEST   Changed Description
PERSON GENDER AT REGISTRATION   Changed Aliases, Description
PERSON GENDER CURRENT   Changed Aliases
PRESCRIPTION DATE   Changed linked Attribute
PROCEDURE DATE   Changed Description
SITE CODE (OF TREATMENT)   Changed Description
SPECIAL EDUCATIONAL NEED TYPE   Changed Description
TREATMENT START DATE (RADIOTHERAPY TREATMENT COURSE)   Changed Description
 

Date:29 March 2010
Sponsor:Richard Kavanagh, NHS Connecting for Health

Note: New text is shown with a blue background. Deleted text is crossed out. Retired text is shown in grey. Within the Diagrams deleted classes and relationships are red, changed items are blue and new items are green.

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APPOINTMENTS

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LISTS

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PATIENT PATHWAY

Change to Diagram: Changed Diagram

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PERSON AND PERSON PROPERTY

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PRESCRIBING AND DISPENSING

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ACUTE MYOCARDIAL INFARCTION DATA SET

Change to Data Set: Changed Aliases, Description

Acute Myocardial Infarction Data Set Overview

Data Set Data Elements MINAP FIELD PROMPT
(Myocardial Infarction Audit Project)
 
Data Set Data ElementsMINAP FIELD PROMPT
(Myocardial Infarction Audit Project)
 
CCAD HOSPITAL IDENTIFIER Hospital Identifier 
LOCAL PATIENT IDENTIFIER Patient Care Record Number 
NHS NUMBER NHS Number 
PERSON FAMILY NAME Patient Surname 
PERSON GIVEN NAME Patient Forename 
BIRTH DATE Patient date of Birth 
SEX Patient Gender 
PATIENT CLINICAL GROUP Patient Ethnic Group 
ADMINISTRATIVE CATEGORY Patient Admin Status 
POSTCODE OF USUAL ADDRESS Patient Post Code 
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) GP Practice Code 
AMI ADMISSION DIAGNOSIS Admission Diagnosis 
INITIAL CONTACT TYPE Method of Admission 
ECG DETERMINING TREATMENT ECG Determining Treatment 
ASPIRIN THERAPY LOCATION Where was Aspirin Given 
PERSON OBSERVATION HISTORY (PREVIOUS AMI) Previous AMI 
PERSON OBSERVATION HISTORY (PREVIOUS ANGINA) Previous Angina 
PERSON OBSERVATION HISTORY (HYPERTENSION) Hypertension 
PERSON OBSERVATION HISTORY (HYPERCHOLESTEROLAEMIA) Hypercholesterloaemia 
PERSON OBSERVATION HISTORY (PERIPHERAL VASCULAR DISEASE) Peripheral Vascular Disease 
PERSON OBSERVATION HISTORY (CEREBROVASCULAR DISEASE) Cerebrovasular Disease 
PERSON OBSERVATION HISTORY (ASTHMA OR COPD) Asthma or COPD 
PERSON OBSERVATION HISTORY (CHRONIC RENAL FAILURE) Chronic Renal Failure 
PERSON OBSERVATION HISTORY (HEART FAILURE) Heart Failure 
CARDIAC ENZYMES OR MARKERS RAISED Cardiac Enzymes/Markers Raised 
SERUM CHOLESTEROL Serum Cholesterol 
SMOKING STATUS Smoking Status 
PERSON OBSERVATION HISTORY (DIABETES TYPE) Diabetes 
PERSON HISTORY (PREVIOUS PCI) Previous PCI 
PERSON HISTORY (PREVIOUS CABG) Previous CABG 
SYSTOLIC PRESSURE (FIRST AFTER ADMISSION) Systolic BP 
AMI HEART RATE Heart Rate 
AMI ADMITTING CONSULTANT TYPE Admitting Consultant 
SYMPTOM ONSET DATE AND TIME (AMI) Date/time of symptom onset 
INITIAL PATIENT CONTACT DATE AND TIME Date/time of call for help 
PROFESSIONAL HELP ARRIVAL DATE AND TIME (AMI) Date/time of arrival of first professional help 
EMERGENCY SERVICES ARRIVAL DATE AND TIME (AMI) Date/time of arrival of emergency services 
START DATE (HOSPITAL PROVIDER SPELL) Date/time of arrival at hospital 
REPERFUSION TYPE (INITIAL STRATEGY) Was Reperfusion Attempted 
THROMBOLYTIC TREATMENT NOT GIVEN REASON Reason Thrombolytic Treatment Not Given 
REPERFUSION TREATMENT DATE AND TIME Date/time of reperfusion treatment 
THROMBOLYTIC TREATMENT DELAY REASON Justified Delay Before Thrombolytic Treatment 
REPERFUSION TREATMENT LOCATION Where was Initial Reperfusion Treatment Given 
REPERFUSION INITIAL DECISION Whose Initial Decision To Reperfuse 
CARDIAC ARREST FIRST VERIFIED DATE AND TIME Cardiac arrest date/time - First Arrest Only 
CARDIAC ARREST LOCATION Cardiac arrest location 
CARDIAC ARREST PRESENTING RHYTHM Arrest Presenting Rhythm 
CARDIAC ARREST OUTCOME (FIRST) Outcome of Arrest 
AMI ADMISSION WARD TYPE Admission Ward 
PEAK CREATINE KINASE Peak CK 
PEAK TROPONIN Peak Troponin 
AMI DRUG TREATMENT (UNFRACTIONATED HEPARIN) Unfractionated heparin 
AMI DRUG TREATMENT (LOW MOLECULAR WEIGHT HEPARIN) Low molecular weight heparin 
AMI DRUG TREATMENT (THIENOPYRIDINE PLATELET INHIBITOR) Thienopyridine platelet inhibitor 
AMI DRUG TREATMENT (ORAL ANTI-PLATELET AGENT) Other oral antiplatelet agent 
AMI DRUG TREATMENT (IV 2B AND (OR) 3B AGENT) IV 2b/3a Agent 
AMI DRUG TREATMENT (IV BETA BLOCKER) IB beta blocker 
AMI DRUG TREATMENT (CALCIUM CHANNEL BLOCKER) Calcium channel blocker 
AMI DRUG TREATMENT (IV NITRATE) IV Nitrate 
AMI DRUG TREATMENT (ORAL NITRATE) Oral Nitrate 
AMI DRUG TREATMENT (POTASSIUM CHANNEL MODULATOR) Potassium channel modulator 
AMI DRUG TREATMENT (WARFARIN) Warfarin 
AMI DRUG TREATMENT (ANGIOTENSIN II BLOCKER) Angiotensin II blocker (ARB) 
AMI DRUG TREATMENT (THIAZIDE DIURETIC) Thiazide diuretic 
AMI DRUG TREATMENT (LOOP DIURETIC) Loop diuretic 
AMI DRUG TREATMENT (SPIRONOLACTONE) Spironolactone 
THROMBOLYTIC DRUG Thrombolytic drug 
DISCHARGE DATE (HOSPITAL PROVIDER SPELL) Date of Discharge 
AMI DISCHARGE DIAGNOSIS Discharge Diagnosis 
BLEED COMPLICATION Bleeding complications 
AMI CAUSE OF DEATH IN HOSPITAL Death in Hospital 
DISCHARGED ON BETA BLOCKER Discharged On Beta Blocker 
DISCHARGED ON ANGIOTENSIN INHIBITOR Angiotensin Inhibitor 
DISCHARGED ON STATIN Discharged On Statin 
DISCHARGED ON ANTI-PLATELET DRUG Discharged On Aspirin Or Other Anti-Platelet 
REHABILITATION REFERRAL Cardiac Rehab 
EXERCISE TEST PERFORMED Exercise Test 
ECHOCARDIOGRAPHY PERFORMED Echocardiography 
RADIONUCLIDE STUDY Radionuclide Study 
CORONARY ANGIOGRAPHY PERFORMED Coronary Angiography at this Admission 
CORONARY INTERVENTION PERFORMED Coronary Intervention at this Admission 
REFERRAL REQUEST (AMI INVESTIGATION OR INTERVENTION) Date of referral for investigation/intervention 
DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) Discharge destination 
INVESTIGATION TRANSFER DATE Transfer date for daycares investigation 
ANGIOGRAM DATE Date of angio performed locally 
INTERVENTION DATE (FIRST IN AMI CARE SPELL) Date of first intervention or surgery performed locally 
CCAD HOSPITAL IDENTIFIER (REFERRING) Referral centre 

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ACUTE MYOCARDIAL INFARCTION DATA SET

Change to Data Set: Changed Aliases, Description


CANCER REGISTRATION DATA SET

Change to Data Set: Changed Aliases, Description

Cancer Registration Data Set Overview

Data Set Data Elements 
Data Set Data Elements 
DEMOGRAPHICS:
It is anticipated that some of the demographic data items listed below will be collected by every provider with which the patient has contact.
Where this information is exchanged, the appropriate data item name should be used to identify the particular instance of the data.
Notes:
NHS NUMBER  
LOCAL PATIENT IDENTIFIER  
ORGANISATION CODE (CODE OF PROVIDER)  
CARE SPELL IDENTIFIER  
PERSON FAMILY NAME  
PERSON GIVEN NAME  
PATIENT USUAL ADDRESS (AT DIAGNOSIS)  
POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS)  
PERSON GENDER CURRENT  
PERSON BIRTH DATE  
GENERAL MEDICAL PRACTITIONER (SPECIFIED) This need only be collected by those sites who find it difficult to collect the GP Practice Code below.
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION)  
ORGANISATION CODE (RESPONSIBLE PCT) This need not be collected directly by clinical staff
PERSON FAMILY NAME (AT BIRTH) This is not usually readily available from a hospital PAS system. It should be collected prospectively on contact with the patient.
ETHNIC CATEGORY  
REFERRALS 
REFERRING ORGANISATION CODE  
REFERRER CODE  
CANCER REFERRAL PRIORITY TYPE  
CANCER REFERRAL DECISION DATE  
REFERRAL REQUEST RECEIVED DATE  
CONSULTANT CODE Referred to
MAIN SPECIALTY CODE Can be derived from consultant code
DATE FIRST SEEN  
DELAY REASON REFERRAL TO FIRST SEEN (CANCER OR BREAST SYMPTOMS)  
DELAY REASON COMMENT (FIRST SEEN)  
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE  
CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS  
WAITING TIME ADJUSTMENT (FIRST SEEN)  
WAITING TIME ADJUSTMENT REASON (FIRST SEEN)  
SOURCE OF REFERRAL FOR OUT-PATIENTS  
SITE CODE (OF IMAGING)  
CLINICAL INTERVENTION DATE (CANCER IMAGING)  
CANCER IMAGING MODALITY  
ANATOMICAL EXAMINATION SITE  
INVASIVE LESION SIZE (RADIOLOGICAL DETERMINATION)  
DIAGNOSIS:
These fields should record the definitive diagnosis as known to the hospital in question, based on the information available at the time the items were completed. There will be only one definitive diagnosis entry held.
 
DIAGNOSIS DATE (CANCER)  
PRIMARY DIAGNOSIS (ICD)  
TUMOUR LATERALITY  
BASIS OF DIAGNOSIS (CANCER)  
HISTOLOGY (SNOMED)  
GRADE OF DIFFERENTIATION (AT DIAGNOSIS)  
CANCER CARE PLAN:
There may be a number of cancer care plans, on different dates.
 
MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR Was this cancer care plan discussed at an MDT meeting?
MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) The date of the MDT meeting at which the cancer care plan was discussed
CARE PLAN AGREED DATE  
RECURRENCE INDICATOR  
CANCER CARE PLAN INTENT  
PLANNED CANCER TREATMENT TYPE  
TREATMENT TYPE SEQUENCE  
NO CANCER TREATMENT REASON  
CO-MORBIDITY INDEX FOR ADULTSInvestigations into the possible use of the ACE-27 coding system are continuing.
PERFORMANCE STATUS (ADULT)  
STAGING:
These fields should be recorded at the time that the first cancer care plan is agreed. Cancer registries require the first pre-treatment stage, i.e. the stage at diagnosis.
 
T CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (T CATEGORY)  
N CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (N CATEGORY)  
M CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (M CATEGORY)  
TNM CATEGORY (FINAL PRETREATMENT)  
STAGING CERTAINTY FACTOR (TNM CATEGORY)  
SITE SPECIFIC STAGING CLASSIFICATION  
TNM CATEGORY (INTEGRATED)  
T CATEGORY (INTEGRATED STAGE)  
N CATEGORY (INTEGRATED STAGE)  
M CATEGORY (INTEGRATED STAGE)  
SURGERY AND OTHER PROCEDURES:
This can be adapted for other procedures including interventional radiology, laser treatment, endoscopies etc. and photo-dynamic procedures. This also includes procedures offered as supportive care.
 
SITE CODE (OF SURGERY)  
CONSULTANT CODE Managing consultant code
MAIN SPECIALTY CODE Can be derived from consultant code
CANCER TREATMENT INTENT  
DECISION TO TREAT DATE (SURGERY)  
START DATE (SURGERY HOSPITAL PROVIDER SPELL)  
PROCEDURE DATE  
PRIMARY PROCEDURE (OPCS)  
PROCEDURE (OPCS) This may occur more than once
DISCHARGE DATE (HOSPITAL PROVIDER SPELL)  
DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL)  
PATHOLOGY DETAILS:
It is expected that all the data items on the minimum RCPath data set will be collected. The pathology data items below are a subset of that data set. A patient may have any number of pathology reports, and there may be more than one pathology report per specimen. If the original report is reviewed or revised, then a new pathology module will need to be completed and dated, with the data item 'Second Opinion' on the RCPath data set marked as 'Y'
 
PATHOLOGY INVESTIGATION TYPE  
SAMPLE RECEIPT DATE  
INVESTIGATION RESULT DATE  
CONSULTANT CODE (PATHOLOGIST)  
ORGANISATION CODE (OF REPORTING PATHOLOGY)  
PRIMARY DIAGNOSIS (ICD)  
TUMOUR LATERALITY  
INVASIVE LESION SIZE  
SYNCHRONOUS TUMOUR INDICATOR  
HISTOLOGY (SNOMED)  
GRADE OF DIFFERENTIATION  
CANCER VASCULAR OR LYMPHATIC INVASION  
EXCISION MARGIN  
NODES EXAMINED NUMBER  
NODES POSITIVE NUMBER  
T CATEGORY (PATHOLOGICAL)  
N CATEGORY (PATHOLOGICAL)  
M CATEGORY (PATHOLOGICAL)  
TNM CATEGORY (PATHOLOGICAL)  
SERVICE REPORT IDENTIFIER  
SERVICE REPORT STATUS  
SPECIMEN NATURE  
ORGANISATION CODE (REQUESTED BY)  
CARE PROFESSIONAL CODE (REQUESTED BY)  
T CATEGORY EXTENDED (PATHOLOGICAL)  
M CATEGORY EXTENDED (PATHOLOGICAL)  
CHEMOTHERAPY AND OTHER DRUGS:
Chemotherapy and/or other anti-Cancer and/or Supportive drugs given to the patient during their treatment.
 
SITE CODE (OF CANCER DRUG TREATMENT)  
CONSULTANT CODE Managing Consultant
MAIN SPECIALTY CODE Can be derived from consultant code
DECISION TO TREAT DATE (ANTI-CANCER DRUG REGIMEN)  
DRUG THERAPY TYPE  
DRUG TREATMENT INTENT  
DRUG REGIMEN ACRONYM  
START DATE (ANTI-CANCER DRUG REGIMEN)  
RADIOTHERAPY 
Radiotherapy (Teletherapy):
A course of teletherapy is defined as a string of prescriptions which are consecutive.
 
SITE CODE (OF TELETHERAPY)  
CONSULTANT CODE Managing consultant
DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE)  
CANCER TREATMENT INTENT  
ANATOMICAL EXAMINATION SITE  
START DATE (TELETHERAPY TREATMENT COURSE)  
Radiotherapy (Brachytherapy):
A course of brachytherapy is defined as a string of prescriptions which are consecutive.
 
SITE CODE (OF BRACHYTHERAPY)  
CONSULTANT CODE Managing Consultant
DECISION TO TREAT DATE (BRACHYTHERAPY TREATMENT COURSE)  
CANCER TREATMENT INTENT  
BRACHYTHERAPY TYPE  
ANATOMICAL EXAMINATION SITE  
START DATE (BRACHYTHERAPY TREATMENT COURSE)  
PALLIATIVE CARE:
It is expected that this section will be completed whenever an intervention occurs that involves one face-to-face contact with the patient. It is expected that a Cancer Care Plan will also be completed for the Palliative Care Management Plan.
The Palliative Care data items are in the process of being developed.
DECISION TO TREAT DATE (SPECIALIST PALLIATIVE TREATMENT COURSE)  
START DATE (SPECIALIST PALLIATIVE TREATMENT COURSE)  
CLINICAL TRIALS:
Additional information corresponding to patients ineligible for a trial, or whether there is no trial available, can be recorded if required.
Clinical Trials information will be completed for every Clinical Trial in which the patient is involved
PATIENT TRIAL STATUS (CANCER)  
CANCER CLINICAL TRIAL TREATMENT TYPE  
DEATH DETAILS 
PERSON DEATH DATE  
DEATH LOCATION TYPE  
DEATH CAUSE IDENTIFICATION METHOD  
The data items below will usually not be collected directly by the Trust; information would come from Cancer Registries. 
DEATH CAUSE CODE (IMMEDIATE)  
DEATH CAUSE CODE (CONDITION)  
DEATH CAUSE CODE (UNDERLYING)  
DEATH CAUSE CODE (SIGNIFICANT)  

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CANCER REGISTRATION DATA SET

Change to Data Set: Changed Aliases, Description


DIABETES DATA SET (SUMMARY CORE)

Change to Data Set: Changed Aliases, Description

Diabetes Data Set (Summary Core) Overview

The Diabetes Data Set (Summary Core) is developed to ensure people with diabetes have up to date records of their risk factors, current management, treatment target achievements and arrangements and outcomes of regular surveillance for complications, to help them monitor their care and make informed choices about their management.

The Diabetes Data Set (Summary Core) will also ensure that when people with diabetes meet health care professionals the consultation is fully informed by comprehensive, up to date and accurate information.

Data Set Data Elements-
Data Set Data Elements 
DEMOGRAPHICSNotes:
NHS NUMBER  
BIRTH DATE  
POSTCODE OF USUAL ADDRESS  
SEX  
PERSON DEATH DATE  
DIAGNOSISNotes:
DIAGNOSIS DATE (DIABETES)  
DIABETES TYPE  
PATIENT REVIEW DATANotes:
Clinical Observation Data 
PERSON OBSERVATION (BMI)  
OBSERVATION DATE (BMI)  
SYSTOLIC BLOOD PRESSURE Not mandatory for children <12 years old
OBSERVATION DATE (BLOOD PRESSURE)  
DIASTOLIC BLOOD PRESSURE Not mandatory for children <12 years old
OBSERVATION DATE (BLOOD PRESSURE)  
Laboratory Data 
PERSON OBSERVATION (HbA1c LEVEL)  
OBSERVATION DATE (HbA1c LEVEL)  
PERSON OBSERVATION (SERUM CREATININE LEVEL)  
OBSERVATION DATE (SERUM CREATININE LEVEL)  
PERSON OBSERVATION (URINARY ALBUMIN LEVEL) Not mandatory for children <12 years old
URINARY ALBUMIN LEVEL TESTING METHOD  
ALBUMINURIA STAGE  
OBSERVATION DATE (URINARY ALBUMIN LEVEL)  
PERSON OBSERVATION (SERUM CHOLESTEROL LEVEL) Not mandatory for children <12 years old
OBSERVATION DATE (SERUM CHOLESTEROL LEVEL)  
Eye Examination 
DIABETES ROUTINE REVIEW (EYE)  
OBSERVATION DATE (EYE EXAMINATION) Not mandatory for children <12 years old
Foot Examination 
DIABETES ROUTINE REVIEW (FOOT)  
OBSERVATION DATE (FOOT EXAMINATION)  
Smoking Review 
SMOKING STATUS Not mandatory for children <12 years old
OBSERVATION DATE (SMOKING STATUS)  
PERSONAL MEDICAL HISTORYNotes:
The following occur as a recurring group:  
PROCEDURE CODING (DIABETES RELEVANT OPCS-4)  
OBSERVATION DATE (DIABETES RELEVANT DIAGNOSIS)  
The following occur as a recurring group:  
DIAGNOSTIC CODING (DIABETES RELEVANT READ CODES)  
OBSERVATION DATE (DIABETES RELEVANT DIAGNOSIS)  
The following occur as a recurring group:  
PROCEDURE CODING (DIABETES RELEVANT OPCS-4)  
PROCEDURE DATE  
The following occur as a recurring group:  
PROCEDURE CODING (DIABETES RELEVANT READ CODES)  
PROCEDURE DATE  

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DIABETES DATA SET (SUMMARY CORE)

Change to Data Set: Changed Aliases, Description


GENITOURINARY MEDICINE CLINIC ACTIVITY DATA SET

Change to Data Set: Changed Aliases, Description

Genitourinary Medicine Clinic Activity Data Set Overview

The Opt (Optionality) column indicates the NHS recommendation for the inclusion of data:

M = Mandatory - This data element is mandatory, the message will be rejected by the Health Protection Agency if this data element is absent

R = Required - data must be included where available

The Genitourinary Medicine Clinic Activity Data Set provides essential public health information about sexually transmitted infection diagnoses, treatments and services provided by genitourinary medicine services.

Please note: A PATIENT may have more than one diagnosis, treatment and service per attendance, therefore a row should be transmitted for each GENITOURINARY EPISODE TYPE.

This data set provides essential public health information about sexually transmitted infection diagnoses, treatments and services provided by genitourinary medicine services.

Please note: A PATIENT may have more than one diagnosis, treatment and service per attendance, therefore a row should be transmitted for each GENITOURINARY EPISODE TYPE.

OptGenitourinary Medicine Clinic Activity Data Set Data Elements
OptGenitourinary Medicine Clinic Activity Data Set Data Elements
M
SITE CODE (OF TREATMENT)
M
LOCAL PATIENT IDENTIFIER
R
GENITOURINARY EPISODE TYPE
R
PERSON GENDER CURRENT
R
AGE AT ATTENDANCE DATE
R
SEXUAL ORIENTATION (CURRENT)
R
ETHNIC CATEGORY
R
COUNTRY CODE (BIRTH)
R
ORGANISATION CODE (PCT OF RESIDENCE)
R
LOWER LAYER SUPER OUTPUT AREA (RESIDENCE)
R
FIRST ATTENDANCE
M
ATTENDANCE DATE

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GENITOURINARY MEDICINE CLINIC ACTIVITY DATA SET

Change to Data Set: Changed Aliases, Description


MENTAL HEALTH MINIMUM DATA SET

Change to Data Set: Changed Aliases, Description

Mental Health Minimum Data Set Overview

The Mental Health Minimum Data Set concerns adult PATIENTS (including elderly) who receive care in NHS specialist mental health services. This care is delivered within a Mental Health Care Spell. For some PATIENTS, care will comprise a small number of Out-Patient Appointments over a few weeks. For others, it may extend over many years and include hospital, community, out-patient and day care attendances which may commonly overlap.

The Mental Health Minimum Data Set is assembled and produced for a defined period of time known as the REPORTING PERIOD (which may be monthly, quarterly or annually) and comprises a data set record for each Mental Health Care Spell which occurs wholly or partially within the REPORTING PERIOD.

Data Set Data Elements 
Data Set Data Elements
Patient Demographics
ORGANISATION CODE (CODE OF PROVIDER) 
ORGANISATION CODE (CODE OF COMMISSIONER) 
REPORTING PERIOD (MENTAL HEALTH) 
NHS NUMBER 
ELECTORAL WARD OF USUAL ADDRESS 
ORGANISATION CODE (PCT OF RESIDENCE) 
PERSON GENDER CURRENT 
PERSON MARITAL STATUS 
PERSON BIRTH DATE 
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
ORGANISATION CODE (PCT OF GP PRACTICE) 
MHMDS LOCAL PATIENT IDENTIFIER 
SOCIAL SERVICES CLIENT IDENTIFIER 
ETHNIC CATEGORY 
EMPLOYMENT STATUS (MENTAL HEALTH) 
WEEKLY HOURS WORKED 
ACCOMMODATION STATUS (MENTAL HEALTH) 
SETTLED ACCOMMODATION INDICATOR (MENTAL HEALTH)
YEAR OF FIRST KNOWN PSYCHIATRIC CARE 
Mental Health Care Spell Activity
CARE SPELL IDENTIFIER (MENTAL HEALTH) 
CARE SPELL NUMBER IN REPORTING PERIOD 
MAIN SPECIALTY CODE (MENTAL HEALTH) 
START DATE (MENTAL HEALTH CARE SPELL) 
SOURCE OF REFERRAL FOR MENTAL HEALTH 
END DATE (MENTAL HEALTH CARE SPELL) 
MENTAL HEALTH CARE SPELL END CODE 
SPELL DAYS IN REPORTING PERIOD 
SUSPENDED DAYS IN REPORTING PERIOD 
MHCS SUSPENSION REASON (AT END OF REPORTING PERIOD) 
CPA STANDARD DAYS 
CPA ENHANCED DAYS 
CPA LEVEL (AT END OF REPORTING PERIOD) 
OCCUPATION (CPA CARE COORDINATOR) 
DATE LAST SEEN (CPA CARE COORDINATOR) 
DAYS LIABLE FOR DETENTION 
DAYS OF SUPERVISED DISCHARGE 
LEGAL STATUS CLASSIFICATION CODE (AT END OF REPORTING PERIOD) 
LEGAL STATUS RESTRICTIVENESS (HIGHEST IN REPORTING PERIOD) 
MHC WITHOUT PATIENT CONSENT IN REPORTING PERIOD 
SSSA (NUMBER FOR DETENTION) 
SSSA (NUMBER FOR COMMUNITY CARE) 
DIAGNOSIS (ICD FIRST MOST RECENT) 
DIAGNOSIS (ICD SECOND MOST RECENT) 
DIAGNOSIS (ICD THIRD MOST RECENT) 
DIAGNOSIS (ICD FOURTH MOST RECENT) 
DIAGNOSIS (ICD FIFTH MOST RECENT) 
DIAGNOSIS (ICD SIXTH MOST RECENT) 
DIAGNOSIS (ICD SEVENTH MOST RECENT) 
DIAGNOSIS (ICD EIGHTH MOST RECENT) 
DIAGNOSIS (ICD NINTH MOST RECENT) 
DIAGNOSIS (ICD TENTH MOST RECENT) 
DIAGNOSIS (ICD ELEVENTH MOST RECENT) 
DIAGNOSIS (ICD TWELFTH MOST RECENT) 
HONOS RATING (FIRST IN MHCS) 
HONOS SCORE DATE (FIRST IN MHCS) 
HONOS RATING (MOST RECENT IN MHCS) 
HONOS SCORE DATE (MOST RECENT IN MHCS) 
HONOS RATING (WORST EVER RECORDED) 
HONOS SCORE DATE (WORST EVER RECORDED) 
HONOS RATING (BEST IN LAST TWELVE MONTHS) 
HONOS SCORE DATE (BEST IN LAST TWELVE MONTHS) 
SUPERVISED COMMUNITY TREATMENT TOTAL 
SUPERVISED COMMUNITY TREATMENT RECALLS TOTAL 
SUPERVISED COMMUNITY TREATMENT DISCHARGES TOTAL 
SUPERVISED COMMUNITY TREATMENT REVOCATIONS TOTAL 
LEAVE OF ABSENCE TOTAL 
LEAVE OF ABSENCE TOTAL DAYS 
LEAVE OF ABSENCE END REASON (LAST) 
ABSENCE WITHOUT LEAVE TOTAL 
ABSENCE WITHOUT LEAVE TOTAL DAYS 
ABSENCE WITHOUT LEAVE END REASON (LAST) 
Mental Health Package
BED DAYS (MENTAL HEALTH) 
BED DAYS (MENTAL HEALTH MEDIUM SECURE) 
BED DAYS (MENTAL HEALTH INTENSIVE) 
CARE DAYS (ACUTE HOME-BASED) 
BED DAYS (MENTAL HEALTH NHS COMMUNITY CARE) 
RESIDENTIAL MH NON-NHS COMMUNITY CARE INDICATOR 
DAY CARE ATTENDANCE (MENTAL HEALTH NHS SITE) 
DAY CARE ATTENDANCE MH NON-NHS SITE INDICATOR 
SHELTERED WORK ATTENDANCE INDICATOR 
OUT-PATIENT ATTENDANCE CONSULTANT (MENTAL HEALTH) 
CONTACTS (COMMUNITY PSYCHIATRIC NURSE) 
CONTACTS (CLINICAL PSYCHOLOGIST) 
CONTACTS (OCCUPATIONAL THERAPIST) 
SOCIAL WORKER INVOLVEMENT INDICATOR 
HOME HELP VISIT INDICATOR 
PROCEDURE (READ FIRST MOST RECENT) 
PROCEDURE (READ SECOND MOST RECENT) 
PROCEDURE (READ THIRD MOST RECENT) 
PROCEDURE (READ FOURTH MOST RECENT) 
PROCEDURE (READ FIFTH MOST RECENT) 
PROCEDURE (READ SIXTH MOST RECENT) 
PROCEDURE (READ SEVENTH MOST RECENT) 
PROCEDURE (READ EIGHTH MOST RECENT) 
PROCEDURE (READ NINTH MOST RECENT) 
PROCEDURE (READ TENTH MOST RECENT) 
PROCEDURE (READ ELEVENTH MOST RECENT) 
PROCEDURE (READ TWELFTH MOST RECENT) 
PROCEDURE (ECT TREATMENTS ADMINISTERED) 
ADMISSIONS (MENTAL HEALTH) 
DISCHARGES (MENTAL HEALTH) 
HOSPITAL STAYS LIST (MENTAL HEALTH) 
COMMUNITY SURVIVAL TIMES LIST (MENTAL HEALTH) 
FIRST CONTACT TIMES LIST (MENTAL HEALTH) 
POSTCODE OF USUAL ADDRESS 
MENTAL HEALTH CARE TEAM TYPE (AT END OF REPORTING PERIOD) 
CONTACTS (PHYSIOTHERAPIST) 
CONTACTS (PSYCHOTHERAPY) 
CONTACTS (SOCIAL WORKER) 
OUT-PATIENT DID NOT ATTENDS (MENTAL HEALTH) 
DAY CARE DID NOT ATTENDS (MENTAL HEALTH NHS SITE) 
CONTACTS (NHS DIRECT MENTAL HEALTH) 
CARE PROGRAMME APPROACH REVIEWS (IN REPORTING PERIOD) 
SPELL DEFINITION TYPE (ASSEMBLER MHCS) 
MENTAL HEALTH CARE AND LEGAL STATUS HISTORY 

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MENTAL HEALTH MINIMUM DATA SET

Change to Data Set: Changed Aliases, Description


NATIONAL CANCER DATA SET

Change to Data Set: Changed Aliases, Description

National Cancer Data Set Overview

Site Specific Cancers

Brain and Central Nervous System
Breast Cancer
Colorectal Cancer
Lung Cancer
Head and Neck Cancer
Sarcoma
Skin Cancer
Urological Cancer
Upper GI Cancer
Gynaecological Cancer

Data Set Data Element
Data Set Data Element
Demographics
NHS NUMBER 
LOCAL PATIENT IDENTIFIER 
ORGANISATION CODE (CODE OF PROVIDER) 
CARE SPELL IDENTIFIER 
PERSON FAMILY NAME 
PERSON GIVEN NAME 
PATIENT USUAL ADDRESS (AT DIAGNOSIS) 
POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS) 
SEX 
BIRTH DATE 
GENERAL MEDICAL PRACTITIONER (SPECIFIED) 
GENERAL MEDICAL PRACTICE CODE (PATIENT REGISTRATION) 
ORGANISATION CODE (RESPONSIBLE PCT) 
PERSON FAMILY NAME (AT BIRTH) 
ETHNIC CATEGORY 
Referrals
SOURCE OF REFERRAL FOR CANCER 
REFERRING ORGANISATION CODE 
REFERRER CODE 
CANCER REFERRAL PRIORITY TYPE 
CANCER REFERRAL DECISION DATE 
REFERRAL REQUEST RECEIVED DATE 
CONSULTANT CODE 
MAIN SPECIALTY CODE 
DATE FIRST SEEN 
DELAY REASON REFERRAL TO FIRST SEEN (CANCER OR BREAST SYMPTOMS) 
DELAY REASON COMMENT (FIRST SEEN) 
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE 
CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS 
WAITING TIME ADJUSTMENT (FIRST SEEN) 
WAITING TIME ADJUSTMENT REASON (FIRST SEEN) 
SOURCE OF REFERRAL FOR OUT-PATIENTS 
Imaging
SITE CODE (OF IMAGING) 
CLINICAL INTERVENTION DATE (CANCER IMAGING) 
CANCER IMAGING MODALITY 
ANATOMICAL EXAMINATION SITE 
INVASIVE LESION SIZE (RADIOLOGICAL DETERMINATION) 
Diagnosis
DIAGNOSIS DATE (CANCER) 
PRIMARY DIAGNOSIS (ICD) 
TUMOUR LATERALITY 
BASIS OF DIAGNOSIS (CANCER) 
HISTOLOGY (SNOMED) 
GRADE OF DIFFERENTIATION (AT DIAGNOSIS) 
Cancer Care Plan
MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR 
MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) 
CARE PLAN AGREED DATE 
RECURRENCE INDICATOR 
CANCER CARE PLAN INTENT 
PLANNED CANCER TREATMENT TYPE 
TREATMENT TYPE SEQUENCE 
NO CANCER TREATMENT REASON 
PERFORMANCE STATUS (ADULT) 
Staging
T CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (T CATEGORY) 
N CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (N CATEGORY) 
M CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (M CATEGORY) 
TNM CATEGORY (FINAL PRETREATMENT) 
STAGING CERTAINTY FACTOR (TNM CATEGORY) 
SITE SPECIFIC STAGING CLASSIFICATION 
TNM CATEGORY (INTEGRATED) 
T CATEGORY (INTEGRATED STAGE) 
N CATEGORY (INTEGRATED STAGE) 
M CATEGORY (INTEGRATED STAGE) 
Surgery and Other Procedures
SITE CODE (OF SURGERY) 
CONSULTANT CODE 
MAIN SPECIALTY CODE 
CANCER TREATMENT INTENT 
DECISION TO TREAT DATE (SURGERY) 
START DATE (SURGERY HOSPITAL PROVIDER SPELL) 
PROCEDURE DATE 
PRIMARY PROCEDURE (OPCS) 
PROCEDURE (OPCS) 
DISCHARGE DATE (HOSPITAL PROVIDER SPELL) 
DISCHARGE DESTINATION (HOSPITAL PROVIDER SPELL) 
Pathology Details
PATHOLOGY INVESTIGATION TYPE 
SAMPLE RECEIPT DATE 
INVESTIGATION RESULT DATE 
CONSULTANT CODE (PATHOLOGIST) 
ORGANISATION CODE (OF REPORTING PATHOLOGY) 
PRIMARY DIAGNOSIS (ICD) 
TUMOUR LATERALITY 
INVASIVE LESION SIZE 
SYNCHRONOUS TUMOUR INDICATOR 
HISTOLOGY (SNOMED) 
GRADE OF DIFFERENTIATION 
CANCER VASCULAR OR LYMPHATIC INVASION 
EXCISION MARGIN 
NODES EXAMINED NUMBER 
NODES POSITIVE NUMBER 
T CATEGORY (PATHOLOGICAL) 
N CATEGORY (PATHOLOGICAL) 
M CATEGORY (PATHOLOGICAL) 
TNM CATEGORY (PATHOLOGICAL) 
SERVICE REPORT IDENTIFIER 
SERVICE REPORT STATUS 
SPECIMEN NATURE 
ORGANISATION CODE (REQUESTED BY) 
CARE PROFESSIONAL CODE (REQUESTED BY) 
T CATEGORY EXTENDED (PATHOLOGICAL) 
M CATEGORY EXTENDED (PATHOLOGICAL) 
Chemotherapy and other drugs
SITE CODE (OF CANCER DRUG TREATMENT) 
CONSULTANT CODE 
MAIN SPECIALTY CODE 
DECISION TO TREAT DATE (ANTI-CANCER DRUG REGIMEN) 
DRUG THERAPY TYPE 
DRUG TREATMENT INTENT 
DRUG REGIMEN ACRONYM 
START DATE (ANTI-CANCER DRUG REGIMEN) 
RECORDED HEIGHT (CANCER DRUG TREATMENT) 
RECORDED WEIGHT (CANCER DRUG TREATMENT) 
PERSON BODY SURFACE AREA (PRETREATMENT) 
CREATININE CLEARANCE 
START DATE (ANTI-CANCER DRUG FRACTION) 
ANTI-CANCER DRUG CYCLE IDENTIFIER 
DAY NUMBER (ANTI-CANCER DRUG CYCLE) 
DURATION OF ANTI-CANCER DRUG CYCLE 
DRUG PROGRAMME RESPONSE 
PLANNED TREATMENT CHANGE REASON 
HEALTHCARE RESOURCE GROUP CODE 
Radiotherapy (Teletherapy)
SITE CODE (OF TELETHERAPY) 
CONSULTANT CODE 
DECISION TO TREAT DATE (TELETHERAPY TREATMENT COURSE) 
CANCER TREATMENT INTENT 
START DATE (TELETHERAPY TREATMENT COURSE) 
END DATE (TELETHERAPY TREATMENT COURSE) 
RADIOTHERAPY PRESCRIBED DOSE 
TELETHERAPY PRESCRIBED FRACTIONS 
RADIOTHERAPY PRESCRIBED DURATION 
RADIOTHERAPY ACTUAL DOSE 
TELETHERAPY ACTUAL FRACTIONS 
DURATION OF TELETHERAPY TREATMENT COURSE 
TELETHERAPY BEAM TYPE 
TELETHERAPY BEAM ENERGY 
TELETHERAPY FIELDS CLASSIFICATION 
TELETHERAPY COMPLEXITY GROUP 
RADIOTHERAPY ANAESTHETIC 
TELETHERAPY MULTIPLE PLANNING 
HEALTHCARE RESOURCE GROUP CODE 
TREATMENT COURSE STATUS 
Radiotherapy (Brachytherapy)
SITE CODE (OF BRACHYTHERAPY) 
CONSULTANT CODE 
DECISION TO TREAT DATE (BRACHYTHERAPY TREATMENT COURSE) 
CANCER TREATMENT INTENT 
BRACHYTHERAPY TYPE 
START DATE (BRACHYTHERAPY TREATMENT COURSE) 
END DATE (BRACHYTHERAPY TREATMENT COURSE) 
RADIOTHERAPY PRESCRIBED DOSE 
BRACHYTHERAPY PRESCRIBED FRACTIONS 
RADIOTHERAPY PRESCRIBED DURATION 
RADIOTHERAPY ACTUAL DOSE 
BRACHYTHERAPY DOSE RATE 
DURATION OF BRACHYTHERAPY TREATMENT COURSE 
BRACHYTHERAPY ISOTOPE TYPE 
RADIOTHERAPY ANAESTHETIC 
UNSEALED SOURCE PATIENT TYPE 
BRACHYTHERAPY DELIVERY TYPE 
HEALTHCARE RESOURCE GROUP CODE 
TREATMENT COURSE STATUS 
Palliative Care
DECISION TO TREAT DATE (SPECIALIST PALLIATIVE TREATMENT COURSE) 
START DATE (SPECIALIST PALLIATIVE TREATMENT COURSE) 
Clinical Trials
PATIENT TRIAL STATUS (CANCER) 
CANCER CLINICAL TRIAL TREATMENT TYPE 
Clinical Status Assessment
CLINICAL STATUS ASSESSMENT DATE (CANCER) 
PRIMARY TUMOUR STATUS 
NODAL STATUS 
METASTATIC STATUS 
MARKER RESPONSE STATUS 
PERFORMANCE STATUS (ADULT) 
TREATMENT TYPE (CANCER MORBIDITY) 
MORBIDITY CODE (CANCER SURGERY) 
PATIENT FOLLOW-UP STATUS (CANCER) 
MORBIDITY CODE (CHEMOTHERAPY) 
MORBIDITY CODE (RADIOTHERAPY) 
MORBIDITY CODE (COMBINATION) 
Death Details
PERSON DEATH DATE 
DEATH LOCATION TYPE 
DEATH CAUSE IDENTIFICATION METHOD 
DEATH CAUSE CANCER 
DEATH CAUSE CODE (IMMEDIATE) 
DEATH CAUSE CODE (CONDITION) 
DEATH CAUSE CODE (UNDERLYING) 
DEATH CAUSE CODE (SIGNIFICANT) 
DEATH CODE DISCREPANCY ORIGINATOR 

Data Set Data Element
Waiting Times Details
WAITING TIME ADJUSTMENT (DECISION TO TREAT) 
WAITING TIME ADJUSTMENT (TREATMENT) 
WAITING TIME ADJUSTMENT REASON (DECISION TO TREAT) 
WAITING TIME ADJUSTMENT REASON (TREATMENT) 
DELAY REASON REFERRAL TO TREATMENT (CANCER) 
DELAY REASON (DECISION TO TREATMENT) 
DELAY REASON COMMENT (REFERRAL TO TREATMENT) 
DELAY REASON COMMENT (DECISION TO TREATMENT) 
DECISION TO TREAT DATE (ACTIVE MONITORING) 
START DATE (ACTIVE MONITORING) 
Site-Specific Data Elements

Brain and Central Nervous System

Brain and Central Nervous System
Data Set Data Element
-

Breast Cancer

Breast Cancer
Data Set Data Element
DIAGNOSTIC ROUTE 
BREAST CANCER NURSE SEEN 
RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) 
MENSTRUAL STATUS 
LMP DATE 
CLINICAL EXAMINATION FINDINGS (BREAST CANCER) 
ENDOCRINE THERAPY TYPE 
MARKER LYMPH NODE RESULT 

Colorectal Cancer

Colorectal Cancer
Data Set Data Element
DIAGNOSTIC ROUTE 
COLORECTAL NURSE OR STOMA THERAPIST SEEN 
RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) 
GRADE OF RESPONSIBLE HCP 
PATIENT PROCEDURE RESULT (COLONOSCOPY) 
COLONOSCOPY INCOMPLETE REASON 
COLORECTAL NURSE OR STOMA THERAPIST SEEN 
SURGICAL URGENCY 
THEATRE CASE START TIME 
MARKER LYMPH NODE RESULT 

Head and Neck Cancer

Head and Neck Cancer
Data Set Data Element
PATIENT HISTORY (CANCER DIAGNOSIS) 
YEAR CANCER DIAGNOSED 
PREVIOUS TREATMENT ELSEWHERE 
TOBACCO USAGE TYPE 
SMOKING STATUS 
TOBACCO CHEWING HISTORY 
YEAR STOPPED SMOKING 
ESTIMATED PACK YEARS 
ALCOHOL STATUS 
QUALITY OF LIFE (AT DIAGNOSIS) 
SYMPTOMS FIRST NOTED DATE 
FAMILY OR SURNAME OF RELATION WITH CANCER 
RELATIONSHIP TO PERSON 
PRIMARY DIAGNOSIS OF RELATION (ICD) 
NUTRITIONAL SUPPORT PROVIDED (CANCER) 
NUTRITIONAL SUPPORT PROVIDED TYPE (CANCER) 
NUTRITIONAL PROCEDURE (OPCS) 
NUTRITIONAL PROCEDURE COMPLICATION (ICD) 
CONTACT DATE (DIETICIAN INITIAL) 
CANCER DENTAL ASSESSMENT DATE 
IMAGE REQUEST DATE 
SPEECH AND SWALLOWING ASSESSMENT DATE 

Lung Cancer

Lung Cancer
Data Set Data Element
SMOKING STATUS 
YEAR STOPPED SMOKING 
ESTIMATED PACK YEARS 
COPD PRESENT 
FEV1 ABSOLUTE AMOUNT 
FEV1 PERCENTAGE 

Sarcoma

Sarcoma
Data Set Data Element
BONE SARCOMA LOCATION 
CLOSEST MARGIN 
NECROSIS 
SARCOMA CONDITION FIRST SEEN 
SARCOMA LARGEST DIAMETER 
SARCOMA PART SITE 
SARCOMA PREDISPOSING CONDITION (FAMILY) 
SARCOMA PREDISPOSING CONDITION (OTHER PHYSICAL) 
SARCOMA RELATION TO DEEP FASCIA 
SARCOMA SURGICAL MARGIN 
SARCOMA SURGICAL PROCEDURE TYPE 
SARCOMA TUMOUR SITE 
SOFT TISSUE SARCOMA LOCATION 

Skin Cancer

Skin Cancer
Data Set Data Element
BASAL CELL CLINICAL MORPHOLOGY 
CLINICAL EXCISION MARGIN 
DERMATOLOGIST BODY SITE (SKIN CANCER CARE SPELL) 
DERMATOLOGIST BODY SITE (SKIN CANCER LESION) 
DISTRIBUTION OF LESIONS PRESENT 
GENETICALLY DETERMINED SKIN CANCER TYPE 
NEW LESIONS TREATED NUMBER (CHEMOTHERAPY) 
NEW LESIONS TREATED NUMBER (RADIOTHERAPY) 
NEW LESIONS TREATED NUMBER (SURGERY) 
PATHOLOGY SPECIMEN TYPE 
PATIENT ON IMMUNOSUPPRESSIVE THERAPY 
PERINEURAL INVASION 
PREVIOUS SKIN CANCER 
RECURRENT LESIONS TREATED NUMBER (CHEMOTHERAPY) 
RECURRENT LESIONS TREATED NUMBER (RADIOTHERAPY) 
RECURRENT LESIONS TREATED NUMBER (SURGERY) 
SKIN CANCER LARGEST CLINICAL DIAMETER (SKIN CANCER CARE SPELL) 
SKIN CANCER LARGEST CLINICAL DIAMETER (SKIN CANCER LESION) 
SKIN CANCER NEW RECURRENT INDICATOR 
SKIN CANCER SUBSEQUENT DIAGNOSIS DATE 
SKIN LYMPHOMA CLINICAL MORPHOLOGY 
SKIN TCELL CLINICAL VARIANT 
SKIN TCELL SURFACE AREA 
SKIN TUMOUR STATUS 

Urological Cancer

Urological Cancer
Data Set Data Element
SERUM TUMOUR MARKER PSA 
S CATEGORY FINAL PRETREATMENT 
DRUG ROUTE OF ADMINISTRATION 

Upper GI Cancer

Upper GI Cancer
Data Set Data Element
POSSUM SCORE (AT DIAGNOSIS) 
POSSUM SCORE (AFTER SURGERY) 
RELATIONSHIP TO PERSON 
PRIMARY DIAGNOSIS OF RELATION (ICD) 
SMOKING STATUS 
YEAR STOPPED SMOKING 
ESTIMATED PACK YEARS 
ALCOHOL STATUS 
CO-MORBIDITY (ICD) 
CLINICAL SIGN OR SYMPTOM (ICD) 

Gynaecological Cancer

Gynaecological Cancer
Data Set Data Element
GYNAECOLOGICAL ONCOLOGY ACCREDITATION 

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NATIONAL CANCER DATA SET

Change to Data Set: Changed Aliases, Description


NATIONAL CANCER WAITING TIMES MONITORING DATA SET

Change to Data Set: Changed Aliases, Description

National Cancer Waiting Times Monitoring Data Set Overview

The National Cancer Waiting Times Monitoring Data Set contains the data required for monitoring the cancer waiting time standards introduced by Data Set Change Notice 22/2002, and has been updated to include those introduced by the Cancer Reform Strategy (2007).

The data items are presented in the same order as the Comma Separated Values (.csv) file which can be exported from Provider-based systems and uploaded to the Cancer Waiting Times system. This system is hosted nationally on NHSnet.

The seven columns show whether the data item is Mandatory or Optional for:

-The Health Care Provider where the PATIENT is first seen following a REFERRAL REQUEST with PRIORITY TYPE 'Two Week Wait', or an urgent referral from an NHS Cancer Screening Programme
-The Health Care Provider where the PATIENT receives First Definitive Treatment for cancer following a REFERRAL REQUEST with PRIORITY TYPE 'Two Week Wait', or an urgent referral from an NHS Cancer Screening Programme
-The Health Care Provider where the PATIENT receives second or subsequent treatment for cancer following a REFERRAL REQUEST with PRIORITY TYPE 'Two Week Wait', or an urgent referral from an NHS Cancer Screening Programme
-The Health Care Provider where the PATIENT receives First Definitive Treatment for cancer following a consultant upgrade onto a 62 day Patient Pathway
-The Health Care Provider where the PATIENT receives second or subsequent treatment for cancer following a consultant upgrade onto a 62 day Patient Pathway
-The Health Care Provider where the PATIENT receives First Definitive Treatment for cancer following a REFERRAL REQUEST from another SOURCE OF REFERRAL FOR OUT-PATIENTS or a different PRIORITY TYPE
-The Health Care Provider where the PATIENT receives second or subsequent treatment for cancer following a  REFERRAL REQUEST from another SOURCE OF REFERRAL FOR OUT-PATIENTS or a different PRIORITY TYPE

  • M = Mandatory - the Standard Contract Schedule 5 requires NHS provider ORGANISATIONS to submit this information on a monthly basis.  The Department of Health require the data to be submitted 25 working days after the end of each month or quarter.

  • M* = Mandatory if applicable - the Standard Contract Schedule 5 requires NHS provider ORGANISATIONS to submit this information on a monthly basis, where collection of the item was applicable to them.  The Department of Health require the data to be submitted 25 working days after the end of each month or quarter.

  • O = Optional

  • O* = Optional if applicable

  • N/A = Not Applicable

Data ItemTrust where patient first seen following referral with PRIORITY TYPE 3 'Two Week Wait', or referral is from Cancer Screening ServiceTrust where patient receives first definitive treatment for cancer following referral with PRIORITY TYPE 3 'Two Week Wait', or referral is from Cancer Screening ServiceTrust where patient receives second or subsequent treatment for cancer following referral with PRIORITY TYPE 3 'Two Week Wait', or referral is from Cancer Screening ServiceTrust where patient receives first definitive treatment for cancer following consultant upgrade onto a 62 day patient pathwayTrust where patient receives second or subsequent treatment for cancer following a consultant upgrade onto a 62 day patient pathwayTrust where patient receives first definitive treatment for cancer following referral from another SOURCE OF REFERRAL FOR OUT-PATIENTS or a different PRIORITY TYPETrust where patient receives second or subsequent treatment for cancer following referral from another SOURCE OF REFERRAL FOR OUT-PATIENTS or a different PRIORITY TYPE
NHS NUMBER M M MM MM M
PATIENT PATHWAY IDENTIFIERM M*M*M*M*M*M*
 ORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER) MM*M*M*M*M*M*
DECISION TO REFER DATE (CANCER OR BREAST SYMPTOMS) M* N/A N/A N/A N/A  ON/A
SOURCE OF REFERRAL FOR OUT-PATIENTSM N/A N/A MN/A O N/A 
PRIORITY TYPEMN/A N/A MN/A O N/A 
CANCER REFERRAL TO TREATMENT PERIOD START DATEMMMO N/A O N/A 
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE MN/A MN/A N/A O N/A 
CONSULTANT UPGRADE DATEN/A N/A N/A MN/A O N/A 
ORGANISATION CODE (PROVIDER CONSULTANT UPGRADE) N/A N/A N/A MN/A O N/A 
DATE FIRST SEEN MN/A N/A MN/A O N/A 
ORGANISATION CODE (PROVIDER FIRST SEEN) MN/A N/A N/A  N/A N/A N/A 
WAITING TIME ADJUSTMENT (FIRST SEEN) M*N/A N/A N/A N/A N/A N/A 
WAITING TIME ADJUSTMENT REASON (FIRST SEEN) M* N/A N/A N/A N/A N/A N/A 
DELAY REASON COMMENT (FIRST SEEN) M* N/A N/A M* N/A N/A N/A 
DELAY REASON REFERRAL TO FIRST SEEN (CANCER OR BREAST SYMPTOMS) M* N/A N/A N/A  N/A N/A N/A 
MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR M*M*M*M*M*M*M*
MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER) M*M*M*M*M*M*M*
CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS MMMMMMM
PRIMARY DIAGNOSIS (ICD) N/A MMMMMM
TUMOUR LATERALITY N/A MMMMMM
CANCER TREATMENT EVENT TYPE N/A MMMMMM
METASTATIC SITE N/A M*M*M*M*M*M*
ORGANISATION CODE (PROVIDER DECISION TO TREAT (CANCER))  M*MMMMMM
CANCER TREATMENT PERIOD START DATE N/A MMMMMM
TREATMENT START DATE (CANCER) N/A MMMMMM
CANCER TREATMENT MODALITYN/A MMMMMM
CANCER CARE SETTING (TREATMENT) N/A MMMMMM
CLINICAL TRIAL INDICATOR N/A MMMMMM
ORGANISATION CODE (PROVIDER TREATMENT START DATE (CANCER))N/A MMMMMM
RADIOTHERAPY PRIORITY N/A M*M*M*M*M*M*
RADIOTHERAPY INTENT N/A M*M*M*M*M*M*
DELAY REASON COMMENT (DECISION TO TREATMENT) N/A M*M*M*M*M*M*
DELAY REASON (DECISION TO TREATMENT)N/A M*M*M*M*M*M*
WAITING TIME ADJUSTMENT (TREATMENT)N/A M*M*M*M*M*M*
WAITING TIME ADJUSTMENT REASON (TREATMENT) N/A M* M*M*M*M*M*
DELAY REASON COMMENT (REFERRAL TO TREATMENT) N/A M*N/AM*N/AO*N/A
DELAY REASON REFERRAL TO TREATMENT (CANCER) N/A M*N/AM*N/AO*N/A
DELAY REASON COMMENT (CONSULTANT UPGRADE) N/A M*N/AM*N/AO*N/A
DELAY REASON (CONSULTANT UPGRADE) N/A M*N/AM*N/AO*N/A

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NATIONAL CANCER WAITING TIMES MONITORING DATA SET

Change to Data Set: Changed Aliases, Description


NATIONAL JOINT REGISTRY DATA SET

Change to Data Set: Changed Aliases, Description

National Joint Registry Data Set Overview

Operations to be included in the National Joint Registry database

HIPS Operations to include in the National Joint Registry 
Primary Total joint replacement - i.e. replacement of the femoral head with a stemmed femoral prosthesis and the insertion of an acetabular cupWith cement / Without cement
Primary Hip resurfacing - Resurfacing of the femoral head with surface replacement femoral prosthesis and insertion of an acetabular cup
Revision Revision of total joint replacementWith cement / Without cement
Revision Revision of hip resurfacing
HIPS Operations to exclude from the National Joint Registry 
  Hemiarthroplasty - i.e. replacement of only the femoral head following fracture of the femoral neck)
KNEES Operations to include in the National Joint Registry 
Primary Total knee arthroplasty - i.e. replacement of both tibial and both femoral condyles with or without resurfacing of the patellaWith cement / Without cement
Primary Unicondylar arthroplasty - i.e. replacement of one tibial condyl and one femoral condyl with or without resurfacing of the patella
Primary Patello-femoral replacement - i.e. where the femoral condyles are replaced and the patella is resurfaced
Revision Revision of total knee arthroplastyWith cement / Without cement
Revision Revision of unicondylar arthroplasty
Revision Revision of patello-femoral replacement

Note:
"Re-operations excluding Revisions" - e.g. for dislocation, infection - are not specifically captured in Version Live MDS_v1 of the Data Set. Relevant procedures will be included in Live MDS_v2 following consultation with the National Joint Registry Steering Committee and the Regional Clinical Co-ordinators' Network.

National Joint Registry Data Set - Data Element List
Data Set Data Element
Patient Details
BIRTH DATE 
LANGUAGE 
LANGUAGE USAGE 
LOCAL PATIENT IDENTIFIER 
NHS NUMBER 
PATIENT CONSENT TO RECORDING DATA 
PERSON FAMILY NAME 
PERSON GIVEN NAME 
POSTCODE OF USUAL ADDRESS 
SEX 
Common Operation Details
ADMINISTRATIVE CATEGORY 
LAMINAR FLOW SYSTEM INDICATOR 
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER) 
PATIENT PHYSICAL STATUS 
PROCEDURE DATE 
TYPE OF ANAESTHETIC 
Surgeon Details
CONSULTANT CODE 
GRADE OF RESPONSIBLE HCP 
LOCUM INDICATOR 
OVERSEAS SURGICAL TEAM MEMBER 
Joint Specific Details
IMPLANT BATCH OR LOT NUMBER 
IMPLANT CATALOGUE NUMBER 
IMPLANT CLASSIFICATION CODE 
IMPLANT MANUFACTURER 
IMPLANT MODEL 
JOINT IMPLANT REVISION INDICATOR 
JOINT IMPLANT REVISION REASON 
JOINT REPLACEMENT ANATOMICAL SIDE 
JOINT REPLACEMENT PRIMARY OR REVISION 
JOINT REPLACEMENT REVISION NUMBER 
ORGANISATION CODE (LOCAL PATIENT IDENTIFIER) 
PATIENT DIAGNOSIS IMPLANT INDICATION 
PATIENT PROCEDURE IMPLANT INDICATION 
PROCEDURE DATE 
SURGICAL DEFAULT TECHNIQUE INDICATOR 
Default Technique - Hips
CEMENT GUN USED 
CEMENT MIXING SYSTEM 
CEMENT PRESSURISER USED 
HIP CEMENTING TECHNIQUE TYPE 
HIP SURGERY INCISION TYPE 
HIP SURGERY PATIENT POSITION 
HIP SURGERY TROCHANTER INDICATOR 
IMAGE GUIDED SURGERY INDICATOR 
MINIMALLY INVASIVE SURGERY INDICATOR 
PROSTHESIS CEMENTED 
PULSATILE LAVAGE 
THROMBO PROPHYLAXIS REGIME TYPE 
Default Technique - Knees
IMAGE GUIDED SURGERY INDICATOR 
KNEE REPLACEMENT CEMENT INDICATOR 
KNEE SURGERY FAT PAD REMOVED 
KNEE SURGERY SKIN INCISION METHOD 
KNEE SURGERY SURGICAL APPROACH 
KNEE SURGERY TOURNIQUET USED 
THROMBO PROPHYLAXIS REGIME TYPE 

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NATIONAL JOINT REGISTRY DATA SET

Change to Data Set: Changed Aliases, Description


RADIOTHERAPY DATA SET

Change to Data Set: Changed Aliases, Description

Radiotherapy Data Set Overview

Commissioning Data Set Item (Yes/No)Data Set Data Element
Demographics:
To carry the personal details of the PATIENT. One occurrence of this group is required.
Commissioning Data Set Item (Yes/No)Data Set Data Element
Demographics:
To carry the personal details of the PATIENT. One occurrence of this group is required.
YesATTENDANCE IDENTIFIER 
YesAPPOINTMENT DATE 
YesORGANISATION CODE (CODE OF PROVIDER) 
Radiotherapy Episode Details:
To carry the ACTIVITY details of each radiotherapy episode. One or more occurrences of Radiotherapy Episode Details are permitted for each Tumour.
Radiotherapy Episode Details:
To carry the ACTIVITY details of each radiotherapy episode. One or more occurrences of Radiotherapy Episode Details are permitted for each Tumour.
NoRADIOTHERAPY EPISODE IDENTIFIER 
NoEARLIEST CLINICALLY APPROPRIATE DATE 
NoRADIOTHERAPY PRIORITY 
NoDECISION TO TREAT DATE (RADIOTHERAPY TREATMENT COURSE)
NoTREATMENT START DATE (RADIOTHERAPY TREATMENT COURSE)
Prescription Details:
To carry the details of the PRESCRIPTION . One or more occurrences of Prescription Details are permitted for each Course.
Prescription Details:
To carry the details of the PRESCRIPTION. One or more occurrences of Prescription Details are permitted for each Course.
NoPRESCRIPTION IDENTIFIER 
NoRADIOTHERAPY TREATMENT MODALITY 
NoRADIOTHERAPY TREATMENT REGION
NoANATOMICAL TREATMENT SITE (RADIOTHERAPY) 
NoNUMBER OF TELETHERAPY FIELDS
NoRADIOTHERAPY PRESCRIBED DOSE 
NoPRESCRIBED FRACTIONS
NoRADIOTHERAPY ACTUAL DOSE
NoACTUAL FRACTIONS
Exposure Details:
To carry the details of the radiotherapy exposure, per prescription. One or more occurrences of Exposure Details are permitted for each Course.
NoRADIOTHERAPY FIELD IDENTIFIER 
NoTIME OF EXPOSURE 
NoMACHINE IDENTIFIER 
NoTELETHERAPY BEAM TYPE 
NoTELETHERAPY BEAM ENERGY 

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RADIOTHERAPY DATA SET

Change to Data Set: Changed Aliases, Description


SEXUAL AND REPRODUCTIVE HEALTH ACTIVITY DATA SET

Change to Data Set: Changed Aliases, Description


Sexual and Reproductive Health Activity Data Set Overview

Sexual and Reproductive Health Activity Data Set
Sexual and Reproductive Health Activity Data Set
ORGANISATION DETAILS:
To carry the details of the reporting period and the organisation providing Sexual and Reproductive Health Services. One occurrence of this group is required.
REPORTING PERIOD START DATE 
REPORTING PERIOD END DATE 
ORGANISATION CODE (CODE OF PROVIDER) 
PERSON DEMOGRAPHICS:
To carry the demographic details of the person attending the appointment. One occurrence of this group is permitted.
LOCAL PATIENT IDENTIFIER
PERSON GENDER CURRENT
ETHNIC CATEGORY
ORGANISATION CODE (RESPONSIBLE PCT)
ORGANISATION CODE (PCT OF RESIDENCE)
AGE AT ATTENDANCE DATE
PERSON ATTENDANCE:
To carry the details of the attendance. One occurrence of this group is permitted.
ATTENDANCE DATE
SITE CODE (OF TREATMENT)
INITIAL CONTACT
LOCATION TYPE
CONTRACEPTION SERVICES PROVIDED:
To carry the details of Contraception Services provided at the attendance.
CONTRACEPTION METHOD STATUS
CONTRACEPTION PRINCIPAL METHOD
CONTRACEPTION OTHER METHOD
(Two occurrences may be recorded for each attendance)
CONTRACEPTION METHOD POST COITAL
(Two occurrences may be recorded for each attendance)
SEXUAL AND REPRODUCTIVE HEALTH - OTHER CARE ACTIVITY:
To carry the details of other Sexual and Reproductive Health Care Activity provided at attendance. Up to six instances of this group are permitted.
SEXUAL AND REPRODUCTIVE HEALTH CARE ACTIVITY

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SEXUAL AND REPRODUCTIVE HEALTH ACTIVITY DATA SET

Change to Data Set: Changed Aliases, Description


ADMINISTRATIVE CODES AND CLASSIFICATIONS

Change to Supporting Information: Changed Description


Responsible AgenciesResponsible Agencies

Organisation Data Service:

The Organisation Data Service is responsible for allocating codes to the following ORGANISATIONS in England and Wales:

Administrative codes are used to identify:

  • Individual healthcare ORGANISATIONS including independent providers;
  • Independent Sector Healthcare Providers;
  • Dental and Medical Practices;
  • Practitioners, such as GENERAL PRACTITIONERS, and Hospital CONSULTANTS;
  • the identification of information returned to the Department of Health;
  • the identification of the ORGANISATIONS involved in the electronic exchange of information within the NHS;
  • the identification of the parties involved in the commissioning and administration of an episode of care.

The current coding standards were introduced in 1996 by the Organisation Codes Service (OCS), now the Organisation Data Service. Subsequent revisions to the structure and format of ORGANISATION CODES have given these codes a consistent and stable format. This both reflects the organisational changes in the NHS and protects the codes against future changes to the structure of the NHS.

Codes used in England and Wales to identify ORGANISATIONS in Scotland and Northern Ireland are allocated by agencies working on behalf of the Information Standards Division (Scotland) and the Northern Ireland Department of Health, Social Services and Public Safety. These codes meet NHS coding standards and are included on the Organisation Data Service data set, issued quarterly to NHS users via the online distribution service, Terminology Reference Data Update Distribution Service (TRUD) and through the Organisation Data Service pages on NHSnet.

Code allocation by other agencies:

Several other UK agencies are responsible for issuing or publishing codes (to NHS standards) for the following healthcare ORGANISATIONS and CARE PROFESSIONALS and for maintaining their details. These details are made available in the Organisation Data Service data set, issued quarterly to NHS users via online distribution service, TRUD (Terminology Reference Data Update Distribution Service) and through the Organisation Data Service pages on the NHSnet.

Where treatment for a NHS PATIENT is sub-commissioned to a non-NHS UK provider healthcare ORGANISATION (independent provider and/or Independent Sector Healthcare Provider) but that non-NHS UK provider does not have an ORGANISATION CODE or sites registered with a responsible agency, the default value of 89999 should be used.

For the Organisation Data Service contact details, see Contact Details.

For codes and format see:

ORGANISATION CODE
ORGANISATION DEPARTMENT CODE
ORGANISATION SITE CODE
CONSULTANT CODE
DOCTOR INDEX NUMBER
GENERAL MEDICAL COUNCIL REFERENCE NUMBER
GENERAL MEDICAL PRACTITIONER PPD CODE
GENERAL DENTAL COUNCIL REGISTRATION NUMBER
GENERAL DENTAL PRACTITIONER CODE
PRIVATE CONTROLLED DRUG PRESCRIBER CODE

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ADMITTED PATIENT FLOWS DATA SET OVERVIEW

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Events During the Reporting Period

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ADMITTED PATIENT STOCKS DATA SET OVERVIEW

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Admitted Patient Stocks at the end of the Reporting Period
Admitted Patient Stock Sub Group Ordinary Admissions and Day Case Admissions

and

all PATIENTS who are waiting to be admitted by specified waiting time band from the ELECTIVE ADMISSION LIST on the  REPORTING PERIOD END DATE. This includes PATIENTS with an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE.

and

all PATIENTS who are waiting to be admitted from the ELECTIVE ADMISSION LIST on the REPORTING PERIOD END DATE due to Self-Deferred Admission. This includes PATIENTS with an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE.

and

all PATIENTS who are waiting to be admitted from the ELECTIVE ADMISSION LIST who at the REPORTING PERIOD END DATE are Suspended Patients. This includes PATIENTS with an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE.

  • It includes those PATIENTS who are classified as booked admissions and waiting list admissions; and is inclusive of private PATIENTS and PATIENTS from overseas.

    It excludes those PATIENTS who are classified as planned admissions and for the total number of PATIENTS waiting and waiting by time band also excludes Suspended Patients.

    ELECTIVE ADMISSION TYPE records the classification of the admission.

  • The collection is further sub grouped into a count of day case admissions and ordinary admissions .

    INTENDED MANAGEMENT records whether a PATIENT is intended as an ordinary admission or a day case admission and therefore which WAITING FOR ADMISSION INTENDED MANAGEMENT it is being sub grouped within.

    Summarised Admitted Patient Stock Group Intended Procedures for Ordinary Admissions

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BOOKINGS ADMITTED PATIENT AND OUT-PATIENT PROVIDER DATA SET OVERVIEW

Change to Supporting Information: Changed Description


Provider Admitted Patient and Out-Patient Bookings: Events During the Reporting Period

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CASEMIX SERVICE

Change to Supporting Information: Changed Description

The Casemix Service is delivered by the NHS Information Centre for health and social care.The Casemix Service is delivered by The NHS Information Centre for health and social care.

The Casemix Service designs and refines classifications that are used by the English NHS to describe healthcare ACTIVITY. These classifications underpin Payment by Results from costing through to payment, and support local commissioning and performance management.

The Casemix Service enables the NHS to:

  • support ACTIVITY costing: to inform the national tariff setting processes
  • report PATIENT ACTIVITY information: to ensure that providers are paid for the SERVICES they deliver
  • provide information: to support epidemiological studies and service planning.
For further information on The Casemix Service, see the Information Centre for Health and Social Care website.For further information on The Casemix Service, see The NHS Information Centre for health and social care website. 

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CDS ADDRESSING GRID

Change to Supporting Information: Changed Description

Activity from 1st April 2005

To help determine who has access to Commissioning Data Set data once it has been stored in the Secondary Uses Service, NHS Trusts and Primary Care Trusts need to identify each of those ORGANISATIONS as a CDS COPY RECIPIENT IDENTITY taking all of the following factors into account. Information is required to:

Main commissioners need access to data to monitor Non-Contract Activity as part of the management of their NHS SERVICE AGREEMENTS.

Primary Care Trusts need to monitor in-year referrals to investigate the sources and reasons for Non-Contract Activity.

Independent Sector Treatment Centres are responsible for providing Admitted Patient Care and Out-Patient Attendance Commissioning Data Set and may submit it on their own behalf or via a third party.Independent Sector Treatment Centres are responsible for providing Admitted Patient Care and Out-Patient Attendance Commissioning Data Sets and may submit on their own behalf or via a third party.

Other Independent Sector activity for NHS PATIENTS is the responsibility of the NHS commissioning body for the provision of the appropriate central returns and data sets.

The Department of Health require a complete record of all PATIENTS admitted to or treated as out-patients by NHS hospitals and Primary Care Trusts, including PATIENTS receiving private treatment.The Department of Health require a complete record of all PATIENTS admitted to or treated as out-patients by NHS hospitals and Primary Care Trusts, including PATIENTS receiving private treatment. The record also includes NHS PATIENTS treated electively in the independent sector and overseas visitors.

A PATIENT / NHS SERVICE AGREEMENT entry has been specifically introduced to identify ACTIVITY commissioned by the National Specialised Commissioning Group (NSCG). The code YDD82 should be used as the ORGANISATION CODE (CODE OF COMMISSIONER) for National Specialised Commissioning Group commissioned activity.

THE CDS ADDRESSING GRID - Activity from 1st April 2005

 

CDS PRIME RECIPIENT IDENTITY

 
CDS COPY RECIPIENT IDENTITY 

PATIENT / NHS SERVICE AGREEMENT

 

ORGANISATION CODE (PCT OF RESIDENCE)
 

 

ORGANISATION CODE (RESPONSIBLE PCT) 

 

ORGANISATION CODE (CODE OF COMMISSIONER) 

 

ORGANISATION CODE of ORGANISATION to which costs of treatment accrue 

 
PATIENT registered with General Medical Practitioner Practice with Primary Care Trust NHS SERVICE AGREEMENT M R     
PATIENT not registered with a General Medical Practitioner Practice but resident in an area covered by a Primary Care Trust with a Primary Care Trust NHS SERVICE AGREEMENT M R     
PATIENT registered with a General Medical Practitioner Practice treated as a Non-Contract Activity M R R   
PATIENT not registered with a General Medical Practitioner Practice treated as a Non-Contract Activity M R R   
Overseas visitor exempt from charges and not registered with a General Medical Practitioner Practice M
(TDH00)
 
  R   
Overseas visitor exempt from charges and registered with a General Medical Practitioner Practice M
(TDH00)
 
R R   
Overseas visitor liable for NHS charges and not registered with a General Medical Practitioner Practice M
(VPP00)
 
      
Overseas visitor liable for NHS charges and registered with a General Medical Practitioner Practice M
(VPP00)
 
R     
PATIENT registered with General Medical Practitioner Practice with a Specialised Services and Other Commissioning Consortia Service AgreementM R   R 
PATIENT not registered with General Medical Practitioner Practice with a Specialised Services and Other Commissioning Consortia Service AgreementM R   R 
Private PATIENT M R  

 
  
National Specialised Commissioning Group commissionedM R   R
(YDD82)
 

Key to population codes:
R - Data required for a Commissioning Data Set data flow as part of NHS business rules to meet NHS business requirements.
M - Data is mandatory in the CDS-XML schema and Commissioning Data Set messages will not flow if this data is absent.

Notes:

a) The CDS PRIME RECIPIENT IDENTITY must be allocated on the first creation and submission of a CDS TYPE and must not change even if the ADDRESS or Primary Care Trust of the PATIENT changes during the lifetime of the Commissioning Data Set record otherwise duplicate Commissioning Data Set data may be lodged in the Secondary Uses Service database.

See the supporting information in Commissioning Data Set Submission Protocol for a detailed explanation.

b) Note that if two recipients are identical for example, the ORGANISATION CODE (PCT OF RESIDENCE) may be the same as the ORGANISATION CODE (CODE OF COMMISSIONER), only one entry for that ORGANISATION should be made for that recipient.

c) For further information please refer to Data Set Change Notice 06/2005, Data Set Change Notice 19/2005 and Data Set Change Notice 19/2006.

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CLINICAL DATA SETS MENU

Change to Supporting Information: Changed Description

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DEFAULT CODES SUMMARY TABLE

Change to Supporting Information: Changed Description


Default (or pseudo) codes may be used:

Person Default CodesCode
CONSULTANT: GENERAL MEDICAL COUNCIL REFERENCE NUMBER not knownC9999998
Dental CONSULTANT: GENERAL MEDICAL COUNCIL REFERENCE NUMBER/ GENERAL DENTAL COUNCIL REGISTRATION NUMBER not knownCD999998
Dentist code not applicable (dentist does not have Dental Practice Board number)D9999981
Dentist, Dental Practice Board (DPB) number not knownD9999998
GENERAL MEDICAL PRACTITIONER PPD CODE not knownG9999998
Locum refersCode of GP for whom locum is acting
MIDWIFE M9999998
Ministry of Defence DoctorA9999998
GENERAL MEDICAL PRACTITIONER PPD CODE not applicableG9999981
NURSE N9999998
Other health care professionalH9999998
Overseas visitor exempt from chargesTDH00
Private PATIENTS/Overseas visitor liable for chargesVPP00
REFERRER CODE not applicable, e.g. PATIENT has self-presented or not knownX9999998
Referrer other than GENERAL MEDICAL PRACTITIONER, GENERAL DENTAL PRACTITIONER or CONSULTANT R9999981
Organisation Default CodesCode
Commissioner Code for Ministry of Defence (MoD) HealthcareXMD00
No Registered GP Practice V81997
ORGANISATION CODE (CODE OF PROVIDER) - non-NHS UK provider where no ORGANISATION CODE has been issued89999
ORGANISATION CODE (CODE OF PROVIDER) - non-UK provider where no ORGANISATION CODE has been issued89997
GP Practice Code not applicableV81998
GP Practice Code not knownV81999
Primary Care Trust code not applicable (e.g. overseas visitors, Wales, Scotland or Northern Ireland).
Note: this code must not be used in the Commissioning Data Set (CDS) header. It is not a default Commissioner code.
X98
Primary Care Trust of residence not known
Note: This code must not be used in the Commissioning Data Set header. It is not a default commissioner code.
Q99
Referring ORGANISATION CODE not applicableX99998
Referring ORGANISATION CODE not knownX99999
Strategic Health Authority of residence not knownQ99
Organisation Site Default CodesCode
SITE CODE (OF TREATMENT) - not a hospital site (for use on Out-Patient Commissioning Data Set)R9998
SITE CODE (OF TREATMENT) - non-NHS UK Provider where no ORGANISATION SITE CODE has been issued89999
SITE CODE (OF TREATMENT) - non-UK Provider where no ORGANISATION SITE CODE has been issued89997

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LEARNING DIFFICULTY

Change to Supporting Information: Changed Description

This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

A Learning Difficulty is a type of Special Education Needs, which affects areas of learning, such as reading, writing, spelling, mathematics etc.

There are several levels of Learning Difficulties, such as:

  • Specific Learning Difficulty (SpLD) - a particular difficulty in learning to read, write, spell etc
  • Moderate Learning Difficulty (MLD) - achievements well below expected levels in all or most areas of the curriculum, despite appropriate interventions
  • Severe Learning Difficulty (SLD) - significant intellectual or cognitive impairments
  • Profound and Multiple Learning Difficulty (PMLD) - multiple Learning Difficulties have severe and complex learning needs, in addition they have other significant difficulties, such as physical disabilities or a sensory impairment.
  • Specific Learning Difficulty - a particular difficulty in learning to read, write, spell etc
  • Moderate Learning Difficulty - achievements well below expected levels in all or most areas of the curriculum, despite appropriate interventions
  • Severe Learning Difficulty - significant intellectual or cognitive impairments
  • Profound and Multiple Learning Difficulty - multiple Learning Difficulties have severe and complex learning needs, in addition they have other significant difficulties, such as physical disabilities or a sensory impairment.

For further information on Learning Difficulties, see the teachernet website.

Note: a Learning Disability usually has a significant impact on a PERSON's life. A PERSON with a Learning Disability finds it harder than others to learn, understand and communicate.

 

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LEARNING DISABILITY

Change to Supporting Information: Changed Description

This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

A Learning Disability (formerly known as a Mental Handicap and referred to as an Intellectual Disability) is a type of DISABILITY.

A Learning Disability usually has a significant impact on a PERSON's life. A PERSON with a Learning Disability finds it harder than others to learn, understand and communicate.

People with Profound and Multiple Learning Disabilities (PMLD) need full-time help with every aspect of their lives, including eating, drinking, washing, dressing and toileting etc.People with Profound and Multiple Learning Disabilities need full-time help with every aspect of their lives, including eating, drinking, washing, dressing and toileting etc.

Someone is considered to have a Learning Disability when they function at a level of intellectual ability which is significantly lower than their chronological age. This is usually considered to be equivalent to having an Intelligence Quotient (IQ) of seventy or less:

  • Mild Learning Disability (roughly equivalent to an IQ of fifty to seventy) is comparable to the educational term 'Moderate Learning Difficulty'. It is usually caused by a combination of restricted learning and social opportunities plus a high rate of low to average intellectual ability and Learning Disability in close relatives.

  • Moderate-to-profound Learning Disability (roughly equivalent to an IQ below fifty) is comparable to the educational term 'Severe Learning Difficulty'. It usually has a specific biological cause.

Note: A Learning Difficulty is a type of Special Education Need which affects areas of learning, such as reading, writing, spelling, mathematics etc.

Further information on Learning Disabilities, can be found on the internet, for example:

 

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NON-CONTRACT ACTIVITY

Change to Supporting Information: Changed Description

Non-Contract Activity was known as Out Of Area Treatment prior to 1 April 2005.

Non-Contract Activities are covered by NHS SERVICE AGREEMENTS between a commissioner and the Trust providing treatment. The commissioner is identified by the ORGANISATION CODE (CODE OF COMMISSIONER).

Non-Contract Activities cover:

*PATIENTS registered with a General Medical Practitioner Practice or resident in an English Primary Care Trust with which the NHS Trust has no NHS SERVICE AGREEMENT for that treatment or for that service;
*PATIENTS registered with a General Medical Practitioner Practice or resident in Wales, Scotland or Northern Ireland who are not covered by a NHS SERVICE AGREEMENT with the NHS Trust;
*Overseas visitors
 
  • PATIENTS registered with a General Medical Practitioner Practice or resident in an English Primary Care Trust with which the NHS Trust has no NHS SERVICE AGREEMENT for that treatment or for that SERVICE;
  • PATIENTS registered with a General Medical Practitioner Practice or resident in Wales, Scotland or Northern Ireland who are not covered by a NHS SERVICE AGREEMENT with the NHS Trust;
  • Overseas visitors.
  •  

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    ORGANISATIONS INTRODUCTION

    Change to Supporting Information: Changed Description

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    PUBLICATION INFORMATION CONTACT DETAILS

    Change to Supporting Information: Changed Description


    Website: http://www.isb.nhs.uk/

    Email: isb@nhs.net

    Website:  Department of Health website

    Queries:  Contact Us Details

    Email: dhmail@dh.gsi.gov.uk

    The NHS Information Centre for health and social care

    Website:  Information Centre for Health and Social Care websiteWebsite: The NHS Information Centre for Health and Social Care website

    Queries:  Contact Us Details

    Email: enquiries@ic.nhs.uk

    Website: HES online

    Queries: HES queries

    • Clinical Coding general enquiries:

      International Classification of Diseases (ICD-10);
      OPCS-4 Classification of Interventions and Procedures;
      Clinical Terms (The Read Codes);
      SNOMED CT (Systematised Nomenclature of Medicine Clinical Terms)

      For all general enquiries, contact:

      NHS Connecting for Health
      Data Standards and Products Help Desk

    E-mail: datastandards@nhs.net

    Website: http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/

    • Electronic copies of International Classification of Diseases (ICD-10) Volumes 1, 2 and 3
      • The ICD-10 metadata file and its specification;
      • The ICD-10 Codes and Titles (on diskette);
      • The ICD-10 Tables of Equivalence (on diskette);
    • OPCS-4 Classification of Interventions and Procedures;
      • OPCS-4 Codes and Titles;
      • OPCS-4 metadata file;
      • OPCS-4 Tables of Coding Equivalence;
      • Electronic format of Index and Tabular List of OPCS-4;
    • Clinical Terms (The Read Codes) and SNOMED CT® (Systematised Nomenclature of Medicine Clinical Terms) are released to licensees every six months (March and September) via the Terminology Reference Data Update Distribution Service (TRUD).

    Information on the Terminology Reference Data Update Distribution Service (TRUD) can be found at: https://www.uktcregistration.nss.cfh.nhs.uk/trud/

    Hard copy versions of ICD-10 and the Tabular List of OPCS-4 are available from The Stationery Office (formerly HMSO).

    Organisation Data Service
    Hexagon House
    Pynes Hill
    Rydon Lane
    Exeter
    Devon EX2 5SE

    Email: exeter.helpdesk@nhs.net

    Telephone: 01392 251 289

    Organisation Data Service website pages:

    Information on the Terminology Reference Data Update Distribution Service can be found at:
    https://www.uktcregistration.nss.cfh.nhs.uk/trud/

    • Postcodes:

    Office for National Statistics

    Telephone: 0845 601 3034

    Fax: 01633 652747

    Email: info@statistics.gov.uk

    Website: http://www.ons.gov.uk/about

    National Health Service Postcode Directory (NHSPD) Website: http://www.ons.gov.uk/about

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    SECONDARY USES SERVICE

    Change to Supporting Information: Changed Description

    The Secondary Uses Service is designed to provide anonymous patient-based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development.The Secondary Uses Service is designed to provide anonymous PATIENT-based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development.

    The NHS Information Centre for health and social care is establishing a single, secure data environment for the whole of the NHS. Secondary Uses Service provides a consistent environment for the management and linkage of data, allowing better comparison of data across the care sector, together with associated analysis and reporting tools. The Secondary Uses Service provides a consistent environment for the management and linkage of data, allowing better comparison of data across the care sector, together with associated analysis and reporting tools.

    The NHS Information Centre for health and social care is working in partnership with NHS Connecting for Health, which manages the National Programme for IT. This joint programme team is responsible for the development and implementation of the Secondary Uses Service . This joint programme team is responsible for the development and implementation of the Secondary Uses Service.

    More information about the Secondary Uses Service can be found at the NHS Connecting for Health managed website: Secondary Uses Service .Further information about the Secondary Uses Service can be found on the NHS Connecting for Health managed website at Secondary Uses Service.

     

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    SUMMARISED ACTIVITY FLOWS DATA SET OVERVIEW

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    SUMMARISED STOCKS DATA SET OVERVIEW

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    WHAT'S NEW: MARCH 2010  renamed from WHAT'S NEW: JANUARY 2010

    Change to Supporting Information: Changed Name, Description

    Release: March 2010

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1123 (1 April 2010) - DSCN 18/2010 Information Standards Notice (ISN)
    • CR1139 (Immediate) - DSCN 16/2010 Person Weight
    • CR1130 (Immediate) - DSCN 15/2010 Change of name for "The NHS Information Centre for health and social care"
    • CR1013 (April 2010) - DSCN 14/2010 Sexual and Reproductive Health Activity Dataset (SRHAD)
    • CR1125 (Immediate) - DSCN 13/2010 NHS Data Model and Dictionary Maintenance Update - Policy Definitions
    • CR1122 (Immediate) - DSCN 11/2010 Changes to Family Planning References

    Release: January 2010

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1115 (Immediate) - DSCN 10/2010 Data Standards: Updating of e- Government Interoperability Framework and Government Data Standards Catalogue References

    Release: December 2009

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1100 (Immediate) - DSCN 25/2009 NHS Prescription Services Update
    • CR1045 (1 December 2009) - DSCN 17/2009 Referral to Treatment Clock Stop Administrative Event
    • CR1003 (1 December 2009) - DSCN 16/2009 Commissioning Data Sets: Mandation of 18 Week Referral To Treatment Data Items

    Release: November 2009

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1113 (Immediate) - DSCN 24/2009 Information Standards Board for Health and Social Care Update
    • CR1087 (Immediate) - DSCN 23/2009 Health Professions Council Update
    • CR1081 (Immediate) - DSCN 22/2009 Data Standards: NHS Data Model and Dictionary Maintenance Update
    • CR1019 (27 November 2009) - DSCN 21/2009 Data Standards: Organisation Data Service (ODS) - Optical Sites and Optical Headquarters
    • CR1034 (27 November 2009) - DSCN 20/2009 Data Standards: Organisation Data Service (ODS) - Care Homes in England and Wales and their Headquarters

    Release: September 2009

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1065 (1 October 2009) - DSCN 15/2009 Data Standards: Organisation Data Service – Local Health Boards
    • CR1065 (1 October 2009) - DSCN 15/2009 Data Standards: Organisation Data Service Local Health Boards

    Release: June 2009

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1014 (1 June 2009) - DSCN 13/2009 Religious and Other Belief System Affiliation
    • CR1074 (Immediate) - DSCN 12/2009 Data Standards: Care Quality Commission
    • CR1056 (Immediate) - DSCN 11/2009 Data Standards: NHS Data Model and Dictionary Maintenance Update
    • CR1072 (1 December 2009) - DSCN 10/2009 Data Standards: National Radiotherapy Data Set
    • CR1073 (Immediate) - DSCN 09/2009 Central Returns: Diagnostic Waiting Times and Activity Data Set
    • CR1066 (Immediate) - DSCN 08/2009 Data Standards: NHS Prescription Services and NHS Dental Services
    • CR1047 (1 April 2011) - DSCN 07/2009 Data Standards: Diabetic Retinopathy Screening Dataset v3.6 
    • CR1059 (Immediate) - DSCN 06/2009 Data Standard: National Workforce Data Set v2.1
    • CR914 (April 2008 (Retrospective)) - DSCN 05/2009 NHS Stop Smoking Services Quarterly Monitoring Return
    • CR899 (Immediate) - DSCN 02/2009 NHS Data Model and Dictionary Maintenance Update

    Release: March 2009

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1001 (1 April 2009) - DSCN 03/2009 Introduction of Commissioning Data Set Schema Version 6-1 (2008-04-01) and update to Commissioning Data Set Schema Version 6-0 (2008-01-14)
    • CR976 (31 March 2009) - DSCN 26/2008 Subject: KP90 - Admissions, Changes in Status and Detentions under the Mental Health Act
    • CR1017 (1 April 2009) - DSCN 25/2008 Critical Care Minimum Data Set
    • CR1002 (1 April 2009) - DSCN 24/2008 Data Standards: Introduction of Commissioning Dataset Version 6.1
    • CR1016 (Immediate) - DSCN 23/2008 4 Byte Version of the Read Codes - Withdrawal

    Release: December 2008

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1022 (1 January 2009) - DSCN 29/2008 Data Standards: 18 Weeks Referral to Treatment (RTT) Time, Performance Sharing
    • CR901 (Immediate) - DSCN 28/2008 Removal of references to EDIFACT and the NHS Wide Clearing Service (NWCS) 
    • CR843 (1 April 2009) - DSCN 22/2008 Data Standards: National Radiotherapy Data Set
    • CR1011 (1 January 2009) - DSCN 20/2008 Data Standards: National Cancer Waiting Times Minimum Data Set 

    Release: November 2008

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1026 (3 November 2008) - DSCN 21/2008 Information Standard: Mental Health Act 2007 Mental Category

    Release: August 2008

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR1018 (Immediate) - DSCN 19/2008 Data Standards: Change of Name for National Administrative Code Services (NACS) to Organisation Data Service (ODS)
    • CR956 (1 September 2008) - DSCN 18/2008 Central Return: Human Papillomavirus (HPV) Immunisation Programme – Vaccine Monitoring Minimum Dataset
    • CR956 (1 September 2008) - DSCN 18/2008 Central Return: Human Papillomavirus (HPV) Immunisation Programme Vaccine Monitoring Minimum Dataset
    • CR861 (Immediate) - DSCN 16/2008 Central Return:  Hospital and Community Services Complaints and General Practice (including Dental) Complaints - KO41(a) and KO 41(b)
    • CR964 (Immediate) - DSCN 14/2008 Central Return: 18 Weeks ‘Adjusted’ Referral to Treatment (RTT) Dataset
    • CR965 (Immediate) - DSCN 13/2008 Data Standards: Organisation Data Service (ODS) - Change to the Default Codes Set to Support Changes to GMS Contract
    • CR879 (Immediate) - DSCN 12/2008 Data Standards: Quarterly Monitoring: Cancelled Operations Data Set (QMCO)

    Release: May 2008

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR502 (Immediate) - DSCN 10/2008 Data Standards: National Workforce Data Definitions (v2.0)
    • CR910 (1 April 2008) - DSCN 08/2008 Data Standards: National Direct Access Audiology Patient Tracking List (PTL) and Waiting Times (WT) data sets
    • CR900 (Immediate) - DSCN 07/2008 Data Standards: Inter-Provider Transfer Administrative Minimum Data Set
    • CR934 (1 April 2008) - DSCN 06/2008 Data Standards: Mental Health Minimum Data Set (version 3.0)
    • CR935 (Immediate) - DSCN 05/2008 Data Standards: 18 Weeks Rules Suite
    • CR925 (1 September 2008) - DSCN 04/2008 Genitourinary Medicine Clinic Activity Data Set Change to an Information Standard
    • CR942 (1 June 2008) - DSCN 03/2008 General Practice and General Medical Practitioner (GMP) - changes resulting from the introduction of the General Medical Services (GMS) Contract

    Release: February 2008

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR812 (Immediate) - DSCN 01/2008 Central Return: Diagnostics Waiting Times Census Data Set
    • CR881 (31 December 2007) - DSCN 42/2007 Central Return: Referral To Treatment Summary Patient Tracking List
    • CR904 (Immediate) - DSCN 41/2007 Data Standards: Admission Intended Procedure Update
    • CR824 (1 February 2008) - DSCN 39/2007 Data Standards: 48 Hour Genitourinary Medicine Access Monthly Monitoring (GUMAMM)

    Release: November 2007

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR919 (Immediate) - DSCN 38/2007 Data Standards: Mental Health Minimum Data Set Schema
    • CR814 (1 April 2008) - DSCN 37/2007 Data Standards: Introduction of Mental Health Minimum Data Set version 2.1
    • CR930 (31 December 2007) - DSCN 35/2007 Data Standards: A correction to the version 6 Commissioning Data Set schema
    • CR834 (Immediate) - DSCN 34/2007 Data Standards: Referral Request Received Date
    • CR875 (Immediate) - DSCN 33/2007 Data Standards: National Administrative Codes Service: Introduction of codes for the new Pan SHAs
    • CR880 (Immediate) - DSCN 29/2007 Data Standards: Amendments to Doctor Index Number (DIN) Description

    Release: August 2007

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR845 (Immediate) - DSCN 28/2007 Data Standards: Treatment Function Code (Referral to Treatment Period)
    • CR831 (1 October 2007) - DSCN 27/2007 Data Standards: Update to Commissioning Data Set XML Schema v5
    • CR825 (1 October 2007) - DSCN 16/2007 Data Standards: Source of Referral for Outpatients (18 Weeks)

    Release: June 2007

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR799 (31 December 2007) - DSCN 18/2007 Data Standards: Introduction of Commissioning Data Set Version 6
    • CR833 (Immediate) - DSCN 17/2007 Data Standards: Introduction of Commissioning Data Set validation table
    • CR801 (Immediate) - DSCN 15/2007 Data Standards: Cover of Vaccination Evaluated Rapidly (COVER) Return

    Release: May 2007

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR800 (31 December 2007) - DSCN 14/2007 Commissioning Data Set Schema Version 6-0
    • CR856 (1 October 2007) - DSCN 13/2007 Data Standards: Discharge Ready Date
    • CR869 (Immediate) - DSCN 12/2007 Data Standards: Update to Clinical Coding Introduction
    • CR827 (1 October 2007) - DSCN 09/2007 Data Standards: Earliest Reasonable Offer Date
    • CR817 (1 October 2007) - DSCN 08/2007 Data Standards: Introduction of Age into Commissioning Data Sets
    • CR849 (May 2007) - DSCN 07/2007 National Administrative Codes Service: Introduction of new identification codes for Dental Consultants
    • CR822 (Immediate) - DSCN 06/2007 Data Standards: Update to Organisation Codes
    • CR850 (Immediate) - DSCN 05/2007 National Administrative Codes Service: Amendments to Default Codes
    • CR786 (1 April 2007) - DSCN 04/2007 Quarterly Monitoring Accident and Emergency Services (QMAE) Central Return

    Release: February 2007

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR811 (Immediate) - DSCN 03/2007 Diagnostic Waiting Times and Activity
    • CR826 (1 October 2007) - DSCN 02/2007 Extension of Treatment Function to Support the Measurement of 18 Week Referral to Treatment Periods
    • CR813 (1 April 2007) - DSCN 01/2007 Paediatric Critical Care Minimum Data Set
    • CR768 (1 January 2007) - DSCN 18/2006 Changes to the NHS Data Dictionary to support the measurement of 18 week referral to treatment periods
    • CR798 (6 November 2006) - DSCN 19/2006 Commissioning Data Set (CDS) Version 5 XML Message Schema
    • CR776 (1 October 2006) - DSCN 05/2006 Data Standards: Accident and Emergency Enhancements to Investigation and Treatment Codes

    Release: September 2006

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR795 (31 October 2006) - DSCN 22/2006 Organisation Codes / Organisation Site Codes
    • CR792 (1 April 2007) - DSCN 15/2006 Neonatal Critical Care
    • CR719 (1 April 2006) - DSCN 09/2006 Measuring and Recording of Waiting Times
    • CR791 (1 April 2007) - DSCN 13/2006 Priority Type
    • CR774 (1 September 2006) - DSCN 12/2006 Person Marital Status

    Release: May 2006

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR764 (1 April 2006) - DSCN 08/2006 Diagnostics waiting times and activity
    • Correction to menu structure to include Critical Care Minimum Data Set

    Release: April 2006

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR608 (1 October 2006) - DSCN 07/2006 Introduction of Commissioning Data Set Version 5 and its associated XML schema into the NHS Data Dictionary.
    • CR756 (1 September 2005) - DSCN 19/2005 PbR Commissioning for Out of Area Treatments (OATs) and Charge-Exempt Overseas Visitors
    • CR724 (1 April 2006) - DSCN 13/2005 Critical Care Minimum Data Set
    • CR754 (1 April 2006) - DSCN 17/2005 Treatment Function and Main Specialty Code Revisions
    • CR763 (1 April 2006) - DSCN 20/2005 New Treatment Functions for therapy services and anticoagulant service
    • CR767 (Immediate) - DSCN 02/2006 Referral Request Received Date
    • CR690 (1 September 2005) - DSCN 16/2005 Marital Status

    Release: August 2005

    Data Set Change Notices incorporated into the NHS Data Model and Dictionary:

    • CR555 (1 April 2005) - DSCN 11/2005 Data Standards: COVER - Hepatitis B immunisation for babies
    • CR715 (Immediate) - DSCN 10/2005 Data Standards: Treatment Function Codes - correction and clarification of names and descriptions
    • CR706 (1 April 2005) - DSCN 09/2005 Data Standards: Cancer Registration Data Set
    • CR691 (1 July 2005) - DSCN 06/2005 Data Standards: NSCAG Commissioner Code

    For all Information Standards Notices and Data Set Change Notices, see the Information Standards Board for Health and Social Care Website

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    GENERAL MEDICAL PRACTITIONER

    Change to Class: Changed Aliases


    PATIENT

    Change to Class: Changed Attributes

    Attributes of this Class are:
    KNHS NUMBER
    CARER PERMISSION DATE
    CARER SUPPORT INDICATOR
    CHRONICALLY SICK OR DISABLED
    DRUG MISUSE DATABASE NUMBER
    DRUG MISUSER INJECTED EVER
    DRUG MISUSER SHARED NEEDLE EVER
    ENLISTMENT DATE
    INJECTED IN LAST 4 WEEKS
    INTERPRETER REQUIRED INDICATOR
    LAST DISCHARGE DATE
    NHS NUMBER
    NHS NUMBER OLD
    OVERSEAS VISITOR UK ARRIVAL DATE
    REFUGEE OR ASYLUM SEEKER INDICATOR
    SHARED NEEDLE OR SYRINGE IN LAST 4 WEEKS
    YEAR OF FIRST KNOWN PSYCHIATRIC CARE

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    PATIENT ORGANISATION

    Change to Class: Changed Attributes

    Attributes of this Class are:
    KPATIENT ORGANISATION START DATE
    BLOCK OR SPECIAL INDICATOR
    DISPENSING SERVICES PROVIDED
    DISTANCE UNITS
    DISTANCE UNITS ADDITIONAL
    LOCAL PATIENT IDENTIFIER
    PATIENT ORGANISATION END DATE
    PATIENT ORGANISATION TYPE
    REGISTRATION DISCHARGE
    REGISTRATION SOURCE
    REGISTRATION TYPE
    RURAL PRACTICE PAYMENT
    SOCIAL SERVICES CLIENT IDENTIFER
    SOCIAL SERVICES CLIENT IDENTIFIER
    WALKING UNIT
    WALKING UNIT ADDITIONAL

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    PRESCRIPTION

    Change to Class: Changed Description

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    ADMINISTRATIVE CATEGORY CODE

    Change to Attribute: Changed Description

    This is recorded for PATIENT activity.This is recorded for PATIENT ACTIVITY.

    The category 'amenity patient' of the classification is only applicable to PATIENTS using a Hospital Bed.The category 'amenity PATIENT' of the classification is only applicable to PATIENTS using a Hospital Bed.

    National Codes:

    01NHS PATIENT, including overseas visitors charged under Section 121 of the NHS Act 1977 as amended by Section 7(12) and (14) of the Health and Medicine Act 1988
    02Private patient, one who uses accommodation or services authorised under section 65 and/or 66 of the NHS Act 1977 (Section 7(10) of Health and Medicine Act 1988 refers) as amended by Section 26 of the National Health Service and Community Care Act 1990
    03Amenity patient, one who pays for the use of a single room or small ward in accord with section 12 of the NHS Act 1977, as amended by section 7(12) and (14) of the Health and Medicine Act 1988
    04Category II patient, one for whom work is undertaken by hospital medical or dental staff within category II as defined in paragraph 37 of the Terms and Conditions of Service of Hospital Medical and Dental Staff.
    02Private PATIENT, one who uses accommodation or services authorised under section 65 and/or 66 of the NHS Act 1977 (Section 7(10) of Health and Medicine Act 1988 refers) as amended by Section 26 of the National Health Service and Community Care Act 1990
    03Amenity PATIENT, one who pays for the use of a single room or small ward in accord with section 12 of the NHS Act 1977, as amended by section 7(12) and (14) of the Health and Medicine Act 1988
    04Category II PATIENT, one for whom work is undertaken by hospital medical or dental staff within category II as defined in paragraph 37 of the Terms and Conditions of Service of Hospital Medical and Dental Staff.
     

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    CANCER REFERRAL TO TREATMENT PERIOD START DATE

    Change to Attribute: Changed Description

    The Start Date of a Cancer Referral To Treatment Period.  This is a specific type of the attribute ACTIVITY DATE.  A CANCER REFERRAL TO TREATMENT PERIOD START DATE will be one of the following:

    Note that for a SERVICE REQUEST received from the Choose and Book system, the referral is received when the PATIENT's Unique Booking Reference Number (UBRN) is used to book the first outpatient appointment slot (i.e. converted).   See REFERRAL REQUEST RECEIVED DATE.

     

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    DEATH LOCATION TYPE

    Change to Attribute: Changed Description

    A classification of the type of location at which a PERSON suffering from cancer died.A classification of the type of LOCATION at which a PERSON died.

    National Codes:

    1Hospital
    2NHS hospice / specialist palliative care unit
    3Voluntary hospice / specialist palliative care unit
    4Patient's own home
    5Care home
    4PATIENT's own home
    5Care Home
    6Other

    References:
    National Cancer Dataset Version 1.3_ISB October 2002

     

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    INTERPRETER REQUIRED INDICATOR

    Change to Attribute: Changed Description

    This item is being updated for development purposes and the changes have not yet been assured by the Information Standards Board for Health and Social Care.

    Identifies whether an interpreter is required for the purposes of communication, including Sign Language, between a CARE PROFESSIONAL and a PERSON.

    National Codes:

    YYes
    NNo
    ZNot Stated (PERSON asked but declined to provide a response)
     

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    PERSON IDENTIFIER

    Change to Attribute: Changed Description

    An identifier, other than a name, which identifies a PERSON.An identifier, other than a name, which identifies a PERSON, for example a NHS NUMBER etc.

     

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    POSSUM SCORE (AFTER SURGERY)

    Change to Attribute: Changed Aliases, Description

    The Physiological and Operative Severity Score for the Enumeration of Mortality and morbidity after surgery for an Upper GI Cancer Care Spell. Further information can be found in the Upper GI Appendix on http://www.The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) after surgery for an Upper GI Cancer Care Spell.

    Further information can be found in the Upper GI Appendix on http://www.ic.nhs.uk/datasets/downloads/cancer/canceruk/webfiles/Services/Datasets/cANCER/appuppergi.pdf.

    References:
    National Cancer Dataset Version 1.3_ISB October 2002

     

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    POSSUM SCORE (AFTER SURGERY)

    Change to Attribute: Changed Aliases, Description


    POSSUM SCORE (AT DIAGNOSIS)

    Change to Attribute: Changed Aliases, Description

    The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity at the point of diagnosis for an Upper GI Cancer Care Spell. Further information can be found in the Upper GI Appendix on http://www.The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) at the point of diagnosis for an Upper GI Cancer Care Spell.

    Further information can be found in the Upper GI Appendix on http://www.ic.nhs.uk/datasets/downloads/cancer/canceruk/webfiles/Services/Datasets/cANCER/appuppergi.pdf.

    References:
    National Cancer Dataset Version 1.3_ISB October 2002

     

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    POSSUM SCORE (AT DIAGNOSIS)

    Change to Attribute: Changed Aliases, Description


    REQUEST CATEGORY

    Change to Attribute: Changed Description

    A classification of DIAGNOSTIC TEST REQUEST including the category of PATIENT (NHS or private) and the type of location from which the request was sent.

    Classification:

    a.Request in respect of a NHS patient, including amenity patients and overseas visitors charged under section 121 of the NHS Act 1977 as amended by Section 7(12) and (14) of the Health and Medicine Act 1988:
     i.from NHS facilities of another provider
     ii.being treated in a non-NHS institution
     iii.being treated in other than i or ii
    b.Request in respect of a private patient using accommodation or services authorised under Section 65 or 66 of the NHS Act 1977 (Section 7(10) of the Health and Medicine Act 1988 refers) as amended by Section 26 of the National Health Service and Community Care Act 1990
    c.Request in respect of a private patient in a non-NHS institution under a contractual arrangement when a Primary Care Trust or NHS Trust is providing a service to the institution in accord with Section 58 of the NHS Act 1977
    b.Request in respect of a private PATIENT using accommodation or services authorised under Section 65 or 66 of the NHS Act 1977 (Section 7(10) of the Health and Medicine Act 1988 refers) as amended by Section 26 of the National Health Service and Community Care Act 1990
    c.Request in respect of a private PATIENT in a non-NHS institution under a contractual arrangement when a Primary Care Trust or NHS Trust is providing a service to the institution in accord with Section 58 of the NHS Act 1977
    d.Category II request; those received as a result of work undertaken by hospital doctors within the scope of category II of the Schedule to paragraph 37 of the Terms and Conditions of Hospital Medical and Dental Staff. For example, requests may arise from examinations and reports on prospective emigrants for insurance and legal purposes and on behalf of the Employment Medical Advisory Service
    e.Request in respect of other human sources:
     i.from a NHS facility or
     ii.from a non-NHS institution under a contractual arrangement as specified at (c)
    f.Request in respect of a non-human source from any non-NHS organisation
    g.Request in respect of a non-human source from a NHS organisation
    f.Request in respect of a non-human source from any non-NHS ORGANISATION
    g.Request in respect of a non-human source from a NHS ORGANISATION
     
     

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    SOCIAL SERVICES CLIENT IDENTIFIER  renamed from SOCIAL SERVICE CLIENT IDENTIFIER

    Change to Attribute: Changed Name

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    SPECIAL EDUCATIONAL NEED TYPE

    Change to Attribute: Changed Description

    This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

    The type of Special Education Needs of a PERSON.

    National Codes:

    01Specific Learning Disability
    01Specific Learning Disability
    02Moderate Learning Difficulty
    03Severe Learning Difficulty
    04Profound and Multiple Learning Difficulty
    05Emotional and Behavioural Difficulty
    06Speech and Communication Difficulty
    07Hearing Impairment
    08Visual Impairment
    09Multi-Sensory Impairment
    10Physical Disability
    10Physical DISABILITY
    11Autistic Spectrum Disorder
    12Other Difficulty / Disability
    12Other Difficulty / DISABILITY
    ZNot Stated (PERSON asked but declined to provide a response)
     

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    ADMINISTRATIVE CATEGORY

    Change to Data Element: Changed Description

    Format/length:n2
    HES item:ADMINCAT
    National Codes:See ADMINISTRATIVE CATEGORY CODE
    Default Codes:98 - Not applicable
     99 - Not known: a validation error

    Notes:
    ADMINISTRATIVE CATEGORY is the same as ADMINISTRATIVE CATEGORY CODE.

    Overseas visitors who do not qualify for free NHS treatment can choose to pay for NHS treatment or for private treatment. If they pay for NHS treatment then they should be recorded as NHS PATIENTS.

    The PATIENT's ADMINISTRATIVE CATEGORY may change during an episode or spell. For example, the PATIENT may opt to change from NHS to private health care. In this case, the start and end dates for each new ADMINISTRATIVE CATEGORY PERIOD (episode or spell) should be recorded.

    If the category changes during a Hospital Provider Spell the category on admission is used to derive the 'Category of patient' for Hospital Episode Statistics (HES).If the ADMINISTRATIVE CATEGORY changes during a Hospital Provider Spell the ADMINISTRATIVE CATEGORY (ON ADMISSION) is used to derive the 'Category of PATIENT' for Hospital Episode Statistics (HES).

    Hospital Provider Spell is an ACTIVITY GROUP where the ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.

     

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    ADMITTED PATIENT ELECTIVE ADMISSIONS

    Change to Data Element: Changed Description

    Format/length:n10
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:
    The total number of finished Consultant Episode (Hospital Provider) where the PATIENT was admitted from an ELECTIVE ADMISSION LIST to a Hospital Provider Spell within the REPORTING PERIOD. This includes PATIENTS who have been admitted and then are subsequently sent home without treatment.

    It includes private PATIENTS and PATIENTS from overseas.

    It is the total of number of elective admissions for PATIENTS where:It is the total of number of elective admissions for PATIENTS where:

     a.the ADMISSION OFFER OUTCOME of the OFFER OF ADMISSION is National Code 1 'Patient admitted - treatment commenced' or 5 'Patient admitted - treatment deferred' 
     a.the ADMISSION OFFER OUTCOME of the OFFER OF ADMISSION is National Code 1 'Patient admitted - treatment commenced' or 5 'Patient admitted - treatment deferred' 
    and  
     b.the ADMISSION METHOD of the Hospital Provider Spell ACTIVITY GROUP is National Code 11 'Waiting list' or 12 'Booked' or 13 'Planned'
     b.the ADMISSION METHOD of the Hospital Provider Spell ACTIVITY GROUP is National Code 11 'Waiting list' or 12 'Booked' or 13 'Planned'
    and  
     c.the ACTIVITY DATE of the Consultant Episode (Hospital Provider) ACTIVITY GROUP recording the END DATE is within the period of the REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE.
     c.the ACTIVITY DATE of the Consultant Episode (Hospital Provider) ACTIVITY GROUP recording the END DATE is within the period of the REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE.
      Within the REPORTING PERIOD includes where the DATE is the same as the START DATE or END DATE.
     

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    CDS SENDER IDENTITY

    Change to Data Element: Changed Description

    Format/length:an5
    HES item: 
    National Codes:See ORGANISATION CODE
    Default Codes: 

    Notes:
    This is the identity of the ORGANISATION acting as the Sender of a Commissioning Data Set submission and is represented by that ORGANISATION's ORGANISATION CODE.This is the identity of the ORGANISATION acting as the sender of a Commissioning Data Set submission and is represented by that ORGANISATION's ORGANISATION CODE.

    Definition:
    See ORGANISATION CODE.

    Usage:
    The CDS SENDER IDENTITY is the mandatory 5-character NHS ORGANISATION CODE of the ORGANISATION acting as the physical Sender of Commissioning Data Set submissions.The CDS SENDER IDENTITY is the mandatory 5-character NHS ORGANISATION CODE of the ORGANISATION acting as the physical sender of Commissioning Data Set submissions. The Commissioning Data Set Sender must make sure that the Commissioning Data Set extraction and submission facilities and processes differentiate correctly between:

    Once associated with the a Commissioning Data Set record and submitted to the Secondary Uses Service, the CDS SENDER IDENTITY should not be changed unless great care is taken to delete the original Commissioning Data Set records before any resubmission is undertaken.

    Usually, the CDS SENDER IDENTITY is never altered once assigned. 

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    CLINICAL CONTACT DURATION OF APPOINTMENT

    Change to Data Element: Changed Description

    Format/Length:n3
    HES Item: 
    National Codes: 
    Default Codes: 

    This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

    Notes:
    The duration of the direct clinical contact at an APPOINTMENT in minutes, excluding any administration time prior to or after the contact.The duration of the direct clinical contact at an APPOINTMENT in minutes, excluding any administration time prior to or after the contact and excluding the CARE PROFESSIONAL's travelling time to an APPOINTMENT.

    This is calculated from the Start Time and End Time of the clinical contact at an APPOINTMENT.

    Start Time is the same as attribute ACTIVITY TIME, where ACTIVITY DATE TIME TYPE is National Code 61 'Start Time'.

    End Time is the same as attribute ACTIVITY TIME, where ACTIVITY DATE TIME TYPE is National Code 56 'End Time'.

     

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    CONSULTANT CODE

    Change to Data Element: Changed Description

    Format/length:an8
    HES item:CONSULT
    National Codes: 
    Default Codes:C9999998 - Consultant, General Medical Council (GMC) number not known
     CD999998 - Dental Consultant: General Medical Council (GMC) number/ General Dental Council (GDC) number not known
    Default Codes:C9999998 - CONSULTANT, GENERAL MEDICAL COUNCIL REFERENCE NUMBER not known
     CD999998 - Dental CONSULTANT: GENERAL MEDICAL COUNCIL REFERENCE NUMBER / GENERAL DENTAL COUNCIL REGISTRATION NUMBER not known
     D9999998 - Dentist, Dental Practice Board (DPB) number not known
     M9999998 - Midwife
     N9999998 - Nurse
     M9999998 - MIDWIFE
     N9999998 - NURSE
     H9999998 - Other health care professional


    Notes:


    This is the same as attribute CONSULTANT CODE.

    All Midwife Episodes and attendances are identified in the Commissioning Data Sets and Hospital Episode Statistics by a pseudo MAIN SPECIALTY CODE, 560, see Main Specialty and Treatment Function Codes. A default code is used in the CONSULTANT CODE field to show that a MIDWIFE is the responsible professional. Note that the MIDWIFE's own code is not used. Note that the MIDWIFE's own Nursing and Midwifery Council code is not used.

    All Nursing Episodes and attendances are identified in the Commissioning Data Sets and Hospital Episode Statistics by a pseudo MAIN SPECIALTY CODE, 950, see Main Specialty and Treatment Function Codes. A default code is used in the CONSULTANT CODE field to show that a NURSE is the responsible professional. Note that the NURSE's own Nursing and Midwifery Council code is not used.

     

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    DEFERRED ADMISSIONS (ORDINARY)

    Change to Data Element: Changed Description

    Format/length:n10
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:
    The total number of PATIENTS classified as booked admissions or WAITING LIST admissions, who have an OFFER OF ADMISSION MADE DATE recorded before or on the REPORTING PERIOD END DATE and are still waiting to be admitted from an ELECTIVE ADMISSION LIST to a Hospital Provider Spell for the specified PATIENT CLASSIFICATION of 'ordinary admission' due to Self-Deferred Admission.

    This includes Self-Deferred Admission PATIENTS where the OFFERED FOR ADMISSION DATE has passed by the end of the REPORTING PERIOD.

    It excludes Self-Deferred Admission PATIENTS where the OFFERED FOR ADMISSION DATE has not passed by the end of the REPORTING PERIOD, private PATIENTS, PATIENTS from overseas, elective planned admissions and Suspended Patients.

    It is the total of number of Self-Deferred Admission PATIENTS with an OFFERED FOR ADMISSION DATE still waiting admission where:

     a.no ELECTIVE ADMISSION LIST REMOVAL REASON and ELECTIVE ADMISSION LIST REMOVAL DATE is recorded i.e. the PATIENT is still waiting for admission on the WAITING LIST 
      or
      if recorded, ELECTIVE ADMISSION LIST REMOVAL DATE is after the REPORTING PERIOD END DATE i.e. the PATIENT was waiting for admission on the WAITING LIST as at the end of the REPORTING PERIOD and should therefore be included in the count
    and  
     b.an OFFERED FOR ADMISSION DATE of an OFFER OF ADMISSION is recorded where the OFFER OF ADMISSION MADE DATE is before or on the REPORTING PERIOD END DATE
     b.an OFFERED FOR ADMISSION DATE of an OFFER OF ADMISSION is recorded where the OFFER OF ADMISSION MADE DATE is before or on the REPORTING PERIOD END DATE
      Where more than one OFFER OF ADMISSION is recorded due to PATIENT Self-Deferred Admission, at least one should have an OFFERED FOR ADMISSION DATE before or on the REPORTING PERIOD END DATE even if it is not the latest offer made
      and
      the latest OFFER OF ADMISSION made, the one with the latest OFFER OF ADMISSION MADE DATE, is before or on the REPORTING PERIOD END DATE i.e exclude from the count if the latest offer was made after the end of the REPORTING PERIOD 
    and  
     c.no ELECTIVE ADMISSION SUSPENSION DETAIL has been recorded
      or
      if recorded, the LIST SUSPENSION START DATE is before the REPORTING PERIOD END DATE and the LIST SUSPENSION END DATE is before the REPORTING PERIOD END DATE i.e. no period of suspension is still on-going as at the end of the REPORTING PERIOD.
      Where no LIST SUSPENSION END DATE has been recorded or where the LIST SUSPENSION END DATE is on or after the REPORTING PERIOD END DATE then the period of suspension is still active and the PATIENT should be excluded from the count
    and  
     d.the ADMINISTRATIVE CATEGORY CODE of the ADMINISTRATIVE CATEGORY for the ELECTIVE ADMISSION LIST ENTRY is National Code 01 'NHS patient, including overseas visitors charged under Section 121 of the NHS Act 1977 as amended by Section 7(12) and (14) of the Health and Medicine Act 1988' 
      and
      no OVERSEAS VISITOR STATUS is recorded for the ELECTIVE ADMISSION LIST ENTRY 
    and  
     e.the ELECTIVE ADMISSION EFFECTIVE WAIT START DATE is different to the ORIGINAL DECIDED TO ADMIT DATE 
      and
      the ELECTIVE ADMISSION EFFECTIVE WAIT START DATE is before or on the REPORTING PERIOD END DATE 
    and  
     f.the ELECTIVE ADMISSION TYPE is National Code 11 'Waiting list admission' or 12 'Booked admission'
    and  
     g.the PATIENT CLASSIFICATION is National Code 1 'Ordinary admission''

    Where no Self-Deferred Admission PATIENTS waiting for admissions match the above criteria, a zero value should be recorded.

     

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    HOSPITAL PROVIDER SPELL NUMBER

    Change to Data Element: Changed Description

    Format/length:an12
    HES item:PROVSPNO
    National Codes: 
    Default Codes: 

    Notes:
    A number to provide a unique identifier for each Hospital Provider Spell for a Health Care Provider.HOSPITAL PROVIDER SPELL NUMBER is the same as attribute ACTIVITY IDENTIFIER.

    HOSPITAL PROVIDER SPELL NUMBER is the same as attribute ACTIVITY IDENTIFIERA number to provide a unique identifier for each Hospital Provider Spell for a Health Care Provider.

    Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.

     

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    ORGANISATION CODE (CODE OF PROVIDER)

    Change to Data Element: Changed Description

    Format/length:see ORGANISATION CODE 
    HES item:PROCODE
    National Codes: 
    Default Codes:89997 - Non-UK provider where no organisation code has been issued
     89999 - Non-NHS UK provider where no organisation code has been issued
    Default Codes:89997 - Non-UK provider where no ORGANISATION CODE has been issued
     89999 - Non-NHS UK provider where no ORGANISATION CODE has been issued

    Notes:
    ORGANISATION CODE (CODE OF PROVIDER) is the same as the attribute ORGANISATION CODE.

    This is the ORGANISATION CODE of the ORGANISATION acting as a Health Care Provider.

    For the Commissioning Data Sets, this should always be the ORGANISATION CODE of the Health Care Provider receiving the Payment by Results tariff income.  Where NHS PATIENT care is sub-commissioned to independent or overseas providers, the NHS Service Agreement should specify that the non-NHS provider has requested an identifying ORGANISATION CODE from the Organisation Data Service. Where NHS PATIENT care is sub-commissioned to independent or overseas providers, the NHS SERVICE AGREEMENT should specify that the non-NHS provider has requested an identifying ORGANISATION CODE from the Organisation Data Service.

     

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    ORGANISATION CODE (PCT OF RESIDENCE (MOTHER))

    Change to Data Element: Changed Description

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    PATIENTS FAILED TO ATTEND

    Change to Data Element: Changed Description

    Format/length:n10
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:
    The total number of PATIENTS classified as booked admissions or WAITING LIST admissions, who giving no advanced warning failed to attend for admission from an ELECTIVE ADMISSION LIST to a Hospital Provider Spell within the REPORTING PERIOD.

    It includes private PATIENTS and PATIENTS from overseas, it excludes elective planned admissions, Self-Deferred Admission by the PATIENT and Suspended Patients.

    It is the total of number of failed to attend for Elective Admission for PATIENTS where:

     a.the ADMISSION OFFER OUTCOME of the OFFER OF ADMISSION is National Code 4 'Patient failed to arrive' 
     a.the ADMISSION OFFER OUTCOME of the OFFER OF ADMISSION is National Code 4 'Patient failed to arrive' 
    and  
     b.the OFFERED FOR ADMISSION DATE of the OFFER OF ADMISSION for the Elective Admission List entry is within the period of the REPORTING PERIOD START DATE and the REPORTING PERIOD END DATE 
      Within the REPORTING PERIOD includes where the DATE is the same as the START DATE or END DATE 
    and  
     c.no ELECTIVE ADMISSION SUSPENSION DETAIL has been recorded
      or
      if recorded, the LIST SUSPENSION END DATE is before the OFFERED FOR ADMISSION DATE i.e. no period of suspension is still on-going at the DATE failed to attend. Where no LIST SUSPENSION END DATE has been recorded then the period of suspension is still active and should be excluded from the count
    and  
     d.the ELECTIVE ADMISSION TYPE is National Code 11 'Waiting list admission' or 12 'Booked admission'
     

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    PATIENTS REGISTERED BUT NOT OFFERED AN APPOINTMENT TOTAL

    Change to Data Element: Changed Description

    Format/length:n6
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:


    The total number of PATIENTS who made a Genitourinary Medicine REFERRAL REQUEST but did not receive an APPOINTMENT OFFER or an APPOINTMENT DATE, that is where:

     a.there is no APPOINTMENT OFFER 
    or  
     b.there is no APPOINTMENT ACCEPTED DATE 
    and  
     c.REFERRAL REQUEST RECEIVED DATE is within the REPORTING PERIOD.

    This should include PATIENTS that attend a CLINIC OR FACILITY with or without prior notice or APPOINTMENT who leave or are turned away before accessing the service.This should include PATIENTS that attend a CLINIC OR FACILITY with or without prior notice or APPOINTMENT who leave or are turned away before accessing the SERVICE.

     

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    PATIENTS REPORTING SYMPTOMS TOTAL

    Change to Data Element: Changed Description

    Format/length:n6
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:


    The total number of first attendances where the PATIENT reports the presence of symptoms:

     a.PATIENT REPORTED SYMPTOMS INDICATOR is National Code 1 - 'PATIENT reports presence of symptoms (symptomatic)' 
     a.PATIENT REPORTED SYMPTOMS INDICATOR is National Code 1 - 'PATIENT reports presence of symptoms (symptomatic)' 
    and  
     b.the CARE CONTACT TYPE is National Code 40 - 'Genitourinary Care Contact' 
    and  
     c.FIRST ATTENDANCE is National Code 1 - 'First attendance face to face' 
    and  
     d.ATTENDED OR DID NOT ATTEND is either National Code 5 - 'Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT' or National Code 6 - 'Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen' 
     d.ATTENDED OR DID NOT ATTEND is either National Code 5 - 'Attended on time or, if late, before the relevant CARE PROFESSIONAL was ready to see the PATIENT' or National Code 6 - 'Arrived late, after the relevant CARE PROFESSIONAL was ready to see the PATIENT, but was seen' 
    and  
     e.the Genitourinary Care Contact Date is within the REPORTING PERIOD.

    This includes Scheduled Appointments and Unscheduled Appointments.

     

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    PATIENTS WAITING FOR ADMISSION

    Change to Data Element: Changed Description

    Format/length:n10
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:
    The number of PATIENTS classified as booked admissions or WAITING LIST admissions, who are waiting to be admitted from an ELECTIVE ADMISSION LIST to a Hospital Provider Spell for the specified WAITING FOR ADMISSION INTENDED MANAGEMENT on the REPORTING PERIOD END DATE.
    This includes PATIENTS with an OFFER OF ADMISSION MADE DATE recorded before or on the REPORTING PERIOD END DATE.

    PATIENTS WAITING FOR ADMISSION will be further categorised by MAIN SPECIALTY CODE of the ELECTIVE ADMISSION LIST or ADMISSION INTENDED PROCEDURE.

    This includes Self-Deferred Admission PATIENTS where a further OFFERED FOR ADMISSION DATE has been made on or before the end of the REPORTING PERIOD.

    It excludes Self-Deferred Admission PATIENTS where no further OFFERED FOR ADMISSION DATE has been made as at the end of the REPORTING PERIOD, private PATIENTS, PATIENTS from overseas, elective planned admissions and Suspended Patients.

    It is the total of number of PATIENTS waiting Elective Admission where:

     a.no ELECTIVE ADMISSION LIST REMOVAL REASON and ELECTIVE ADMISSION LIST REMOVAL DATE is recorded i.e. the PATIENT is still waiting for admission on the WAITING LIST 
      or
      if recorded, ELECTIVE ADMISSION LIST REMOVAL DATE is after the REPORTING PERIOD END DATE i.e. the PATIENTS was waiting for admission on the WAITING LIST as at the end of the REPORTING PERIOD and should therefore be included in the count
    and  
     b.an OFFERED FOR ADMISSION DATE of an OFFER OF ADMISSION is recorded where the OFFER OF ADMISSION MADE DATE is before or on the REPORTING PERIOD END DATE 
      Where more than one OFFER OF ADMISSION is recorded (due to Self-Deferred Admission), at least one should have an OFFER OF ADMISSION MADE DATE before or on the REPORTING PERIOD END DATE and the latest OFFER OF ADMISSION MADE DATE is before or on the REPORTING PERIOD END DATE i.e exclude from the count if the latest offer was made after the end of the REPORTING PERIOD 
    and  
     c.the ADMINISTRATIVE CATEGORY CODE of the ADMINISTRATIVE CATEGORY for the ELECTIVE ADMISSION LIST ENTRY is National Code 01 'NHS patient, including overseas visitors charged under Section 121 of the NHS Act 1977 as amended by Section 7(12) and (14) of the Health and Medicine Act 1988' 
      and
      no OVERSEAS VISITOR STATUS is recorded for the ELECTIVE ADMISSION LIST ENTRY 
    and  
     d.no ELECTIVE ADMISSION SUSPENSION DETAIL has been recorded
      or
      if recorded, the LIST SUSPENSION START DATE is before the REPORTING PERIOD END DATE and the LIST SUSPENSION END DATE is before the REPORTING PERIOD END DATE i.e. no period of suspension is still on-going as at the end of the REPORTING PERIOD.
      Where no LIST SUSPENSION END DATE has been recorded or where the LIST SUSPENSION END DATE is on or after the REPORTING PERIOD END DATE then the period of suspension is still active and the PATIENT should be excluded from the count
    and  
     e.the ELECTIVE ADMISSION TYPE is National Code 11 'Waiting list admission' or 12 'Booked admission'

    Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.Hospital Provider Spell is an ACTIVITY GROUP where ACTIVITY GROUP TYPE is National Code 21 'Hospital Provider Spell'.

     

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    PATIENTS WAITING FOR DIAGNOSTIC TEST

    Change to Data Element: Changed Description

    Format/length:n6
    HES item: 
    National Codes: 
    Default Codes: 

    Notes:
    This is the number of PATIENTS that have been waiting for a time within a DIAGNOSTICS REPORTING TIME BAND for the particular test or investigation.

    This is derived from the SERVICE REQUEST DATE of the SERVICE REQUEST to the REPORTING PERIOD END DATE or the APPOINTMENT DATE of the last missed APPOINTMENT (if reset due to missed or cancelled APPOINTMENT where ATTENDED OR DID NOT ATTEND are codes 2 Appointment cancelled by, or on behalf of, the PATIENT, 3 Did not attend - no advance warning given or 7 PATIENT arrived late and could not be seen) to the REPORTING PERIOD END DATE.

    This is derived from the SERVICE REQUEST DATE of the SERVICE REQUEST to the REPORTING PERIOD END DATE or the APPOINTMENT DATE of the last missed APPOINTMENT (if reset due to missed or cancelled APPOINTMENT where ATTENDED OR DID NOT ATTEND are codes 2 Appointment cancelled by, or on behalf of, the PATIENT, 3 Did not attend - no advance warning given or 7 PATIENT arrived late and could not be seen) to the REPORTING PERIOD END DATE.

    For pathology diagnostic tests, the total waiting time is measured from the SERVICE REQUEST DATE to the INVESTIGATION RESULT DATE. For other diagnostic test waiting times, it is measured from the SERVICE REQUEST DATE to the Clinical Intervention Date of the CLINICAL INTERVENTION.

     

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    PERSON GENDER AT REGISTRATION

    Change to Data Element: Changed Aliases, Description

    Format/length:1 numeric
    HES item: 
    National Codes:See PERSON GENDER CODE for the National Codes, which may all be used except ' 0 Not Known '.
    Default Codes: 

    Notes:
    A PERSON's gender at registration.

    PERSON GENDER AT REGISTRATION is the same as PERSON GENDER CODE where the PERSON GENDER TYPE equals '01 - Person Gender at Registration'.

    The e-Government Interoperability Framework (e-GIF)standard PERSON GENDER AT REGISTRATION should be used for all new and developing systems and for XML messages.

    References:
    The e-GIF version approved for use in NHS England is:
    Government Data Standards Catalogue: (GDSC), Version 2.0, Agreed 11 September 2003.
    GDSC: http://www.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards.aspx.

     

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    PERSON GENDER AT REGISTRATION

    Change to Data Element: Changed Aliases, Description


    PERSON GENDER CURRENT

    Change to Data Element: Changed Aliases


    PRESCRIPTION DATE

    Change to Data Element: Changed linked Attribute

    PRESCRIPTION DATE
     
    Attribute:
    ACTIVITY DATE
    PRESCRIPTION DATE
    PRESCRIPTION DATE

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    PROCEDURE DATE

    Change to Data Element: Changed Description

    Format/length:see DATE 
    HES item: 
    National Codes: 
    Default Codes: 

    The date of the occurrence of the CLINICAL INTERVENTION.

     Notes:
    The date of the occurrence of the CLINICAL INTERVENTION. 

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    SITE CODE (OF TREATMENT)

    Change to Data Element: Changed Description

    Format/length:see ORGANISATION SITE CODE 
    HES item:SITETRET
    National Codes: 
    Default Codes:R9998 - Not a hospital site (for use on Out-Patient CDS)
     89999 - Non-NHS UK Provider where no ORGANISATION SITE CODE has been issued
     89997 - Non-UK Provider where no ORGANISATION SITE CODE has been issued

    Notes:
    SITE CODE (OF TREATMENT) is the ORGANISATION SITE CODE for the ORGANISATION SITE where the PATIENT was treated.

    Note that the SITE CODE (OF TREATMENT) should always identify an ORGANISATION SITE where ACTIVITY managed by the treating ORGANISATION takes place, i.e. it should enable the treating ORGANISATION to be identified.

    This identifies the site within the ORGANISATION on which the PATIENT was treated, since facilities may vary on different hospital sites. The code recorded should always be the national code; if the treatment is sub-commissioned to another provider, the site code used should be that of the provider actually carrying out the work.

    Each ORGANISATION has a unique ORGANISATION CODE. However, where an ORGANISATION has more than one site from which it provides services then each site is uniquely identified. These sites are ORGANISATION SITES and are uniquely identified by ORGANISATION SITE CODE. The ORGANISATION SITE CODE contains the first 3 digits of the ORGANISATION CODE with the last two digits being the site identifier.

    Example:

    RA700ORGANISATION CODE of the ORGANISATION 
    RA701ORGANISATION SITE CODE of the first identified ORGANISATION SITE within the ORGANISATION 
    RA702ORGANISATION SITE CODE of the second identified ORGANISATION SITE within the ORGANISATION 

    Where treatment for an NHS PATIENT is sub-commissioned to an independent UK provider the appropriate ORGANISATION SITE CODE should be used. Where treatment is sub-commissioned to an overseas provider the default code 89997 is applicable.

    For out-patients, ACTIVITY may take place outside the hospital, such as in the PATIENT'S home; in such cases, raising a site code is impractical.For out-patients, ACTIVITY may take place outside the hospital, such as in the PATIENT's home; in such cases, raising a site code is impractical. LOCATION CLASS is used in the Commissioning Data Set (CDS) message to indicate the classification of the physical LOCATION within which the ACTIVITY occurred.

    Use in the Future Outpatient CDS:
    If the INTENDED SITE CODE (OF TREATMENT) is not known, this data element should be omitted.

     

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    SPECIAL EDUCATIONAL NEED TYPE

    Change to Data Element: Changed Description

    Format/length:an2
    HES item: 
    Format/Length:an2
    HES Item: 
    National Codes:See SPECIAL EDUCATIONAL NEED TYPE
    Default Codes: 

    This item is being used for development purposes and has not yet been assured by the Information Standards Board for Health and Social Care.

    Notes:
    SPECIAL EDUCATIONAL NEED TYPE is the same as attribute SPECIAL EDUCATIONAL NEED TYPE.

     

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    TREATMENT START DATE (RADIOTHERAPY TREATMENT COURSE)

    Change to Data Element: Changed Description

     
    Format/length:see DATE 
    HES item: 
    National Codes: 
    Default Codes:


    Notes:


    This is the DATE that treatment for a PATIENT's condition using a RADIOTHERAPY TREATMENT MODALITY started.

    Where the treatment is being undertaken as part of a Cancer Treatment Period, where the CANCER TREATMENT MODALITY is National Code 05 'Teletherapy' or 06 'Brachytherapy', the TREATMENT START DATE (RADIOTHERAPY TREATMENT COURSE) is the same as the TREATMENT START DATE (CANCER).

     

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    For enquiries, please email datastandards@nhs.net